conception to age 2 – the age of...

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Conception to age 2 - the age of opportunity

Conception to age 2– the age of opportunity

Addendum to the Government’s vision for the Foundation Years: ‘Supporting Families in the Foundation Years’

Cameron House, 61 Friends RoadCroydon, Surrey CR0 1ED

T: 020 8688 3773 F: 020 8688 6135E: [email protected]

W: www.wavetrust.orgISBN-13: 978-0-9551615-3-7

Charity No.1080189

Tackling the roots of disadvantage

Tackling the roots of disadvantage

(June 2013) Contents of 2nd Edition

Foreword and introduction by George Hosking and Sally Burlington

Forewords by Ministers Liz Truss and Dan Poulter

Executive summary 3

Recommendations 7

Supporting chapter 1: The importance of child development from conception to age 2 10

Supporting chapter 2:Making best uses of resources for 0-2s 24

Supporting chapter 3: Intervening early and the economic case for this approach 37

References for the main document 42

Local commissioning for very early child development: A framework 50

References for local commissioning framework 68

Appendices (selected sub-group reports) 1. Mental Health Promotion in children under the age of two 69 2. Social and Emotional Assessments 76 3. Quality and training of the workforce 93 4. The economics of early years’ investment 100 5. Systems 132

We wish to acknowledge Ita Walsh of WAVE Trust for her sterling editing and writing, Pat Branigan of the Department for Education for his tireless and cheerful co-ordination of the processes of this project from start to finish, and the other members of the DfE and WAVE teams for their hard work and support.

Conception to age 2 – the age of opportunity 2013

Acknowledgement of financial supporters

John Spiers

It was John Spiers (Founder and former CEO of Bestinvest) who made possible the WAVE Trust work on boththe Special Interest Group study and the Age of Opportunity report, by funding our labour and overhead costs on the year-long project.

Mere words are inadequate to express our gratitude for this wonderful support of our work to bring the importance of the 0-2 age group to the notice of policy-makers and practitioners.

Erach and Roshan Sadri Foundation

WAVE Trust is also extremely grateful to the Erach and Roshan Sadri Foundation for funding the printing costs of this report.

Erach and Roshan were special and extraordinary people who loved life, took everything in their stride and had a true pioneering spirit. Shortly after their marriage, they went to live in Afghanistan where Roshan taught in an international school in Kabul and Erach flew Dakotas – ‘old tin buckets’ – over some of the most dangerous terrains in the world.

Their Foundation was founded in August 2005, a year after the untimely death of Roshan, to fulfil her request to use her legacy for charitable purposes. The objects of the Charity are to provide financial assistance for education and welfare purposes; relieving poverty by alleviating homelessness; and assisting members of theZoroastrian religious faith.


Foreword and introductionSupporting Families in the Foundation Years stressed the vital importance of early life, both in its own right and for promoting future life chances.

‘The Government’s aim is to put in place a coherent framework of services for families, from pregnancy through to age five, which focus on promoting children’s development and help with all aspects of family life’

The 0-2 Special Interest Group was set up as a time-limited task and finish group of expert practitioners supported by officials from the Departments for Education and Health. Weexplored and considered how best to promote effective implementation of the principles set out in Supporting Families, with specific emphasis on children under the age of 2 and their parents and families. The focus of our report is the period from conception to the child’s second birthday. As well as drawing on the knowledge and experience of the Group, a major part of the work was drawing together external knowledge and research evidence of experience and investment in the earliest months of life.

This report highlights issues for 0-2s for the attention of two main groups: servicecommissioners and decision-makers. For these two key groups influencing services for youngchildren and families, significant messages about effective parenting and evidenced practice with 0-2s are set out in supporting chapters 1 and 3. Other, more specific, messages are summarised in supporting chapter 2, which aims to influence those responsible fordeveloping the future workforce to intervene early and effectively in families who have (orare expecting) really young children, and who need help.

The summary conclusions and recommendations provide an overview of our work. The commissioning framework aims to help commissioners in their thinking about how best to improve child development outcomes through better support in very early childhood.

The Special Interest Group was supported by eight separate sub-groups, seven of which produced reports on the sphere of their particular interest and task. These individual reports fed into this report; some are attached as appendices because they contain so much detailed knowledge and information. We have also called upon findings from other commissioned work and wider research.

While the views have been developed with input from DfE officials, they do not represent a summary of current government policy.

We are indebted to many experts and professionals who made this report possible, in particular the members of the eight sub-groups who gave so generously of their time over aperiod of many months: Cheryll Adams, Robin Balbernie, Christine Bidmead, Mitch Blair, Pat Branigan, Harry Burns, Chris Cuthbert, Sarah Darton, Hazel Douglas, Vivette Glover, Eileen Hayes, Amanda Jones, June O'Sullivan, Pamela Park, Gwynne Rayns, Sue Robb, Catherine Rushforth, P.O. Svanberg, and Ita Walsh.

Sally Burlington, Deputy Director, George Hosking, CEO Sure Start and Early Intervention Division WAVE Trust Department for Education1

1 From August 2012 Head of Programmes, Children & Adults at Local Government Association


I am delighted to be given the opportunity to write a foreward for this report, which Ibelieve represents a very important step in achieving earlier intervention for families whoneed the most support.

As our understanding of the brain development of babies improves, so too must our policies, to reflect this critically important period of life.

If every single child is to benefit from the positive changes we are making to the early child care and education settings, then every single child has to receive ‘good enough’ parenting.The ‘Age of opportunity’ report provides many of those evidence-based answers as to how we can practically implement support for women and families, and promote a generation of improved infant mental health.

Elizabeth Truss MP Parliamentary Under-Secretary of State for Education and Childcare

'We know the importance of strong loving relationships and also the power of earlyintervention for families in the earliest months and years of life. That is why we are investingin a substantial increase in health visitors and in the Family Nurse Partnership for the most vulnerable young parents.

The Age of Opportunity makes a further contribution to the challenges to all of us to improve the physical and mental health of our youngest children and I will be asking the independent Children and Young People's Health Outcomes Forum to study its recommendations carefully.'

Dr Daniel Poulter MPParliamentary Under-Secretary of State for Health Services


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Executive summary

1. A wide range of research now shows that conception to age 2 is a crucial phase of human development and is the time when focused attention can reap great dividends for society.

2. How we treat 0-2 year-olds shapes their lives – and ultimately our society. Loving, secureand reliable relationships with parents, together with the quality of the home learningenvironment, foster a child’s:

o emotional wellbeing (sometimes referred to as infant mental health); o capacity to form and maintain positive relationships with others;o brain development (c.80% of brain cell development takes place by age 3);o language development, ando ability to learn (the ‘soft’ skills that equip a child to relate to others, thrive and then go

on to learn the ‘hard’ cognitive skills needed to succeed academically are embedded

in the earliest months of life. Poor support, particularly a failure to prevent abuse or neglect, at this stage can have a lifelong adverse impact on outcomes).

3. Because we now understand the importance of the 0-2 period in creating solid psychological and neurological foundations to optimise lifelong social, emotional and physical health, and educational and economic achievement, we believe policy emphasis needs to shift to reflect, in particular, that:

o the nature of day-to-day relationship between the child and primary care giver is crucial;

o parental mental health (before and after birth) is a key determinant of the quality of that relationship, and of the ability to provide a number of other conditions for foetal and child development; it is also a key factor in safeguarding children from abuse and neglect;

o policy debates have not given enough emphasis to the impact of multiple risk factors on the likelihood of really poor outcomes for children. These factors impact both practical parenting and levels of secure attachment; and to take account of:

o the numerous evidence-based approaches already in use, which support either improved early relationships or perinatal mental health.

4. Pregnancy is a particularly important period during which the physical and mental wellbeing of the mother can have lifelong impacts on the child. For example, duringpregnancy, such factors as maternal stress, diet and alcohol or drug misuse can place achild’s future development at risk.

5. In the first few months following birth, adequate nutrition is vital to a child’s physical

and intellectual development. Evidence cited in supporting chapter 1 suggests there can be particular benefit from breastfeeding. Good hygiene, home safety and immunisation are also important health promotion factors.

6. There is a clear case for prioritising earlier identification of need and provision of appropriate support for children in their families during this phase, and we have identified a number of helpful approaches, including:

o Taking into consideration the role and methods of social and emotional assessment when revising health visitor and midwifery training;


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o Practice guidance for early years’ practitioners, revisions to the National Professional Qualification in Integrated Centre Leadership (NPQICL) and additional factors to consider in developing the response to the Nutbrown review;

o Use by commissioners of best practice approaches;o Use of professional reflective supervision, including practice to ensure self-awareness

and to ensure the supervisee has emotional intelligence.

7. Such studies as the Californian Adverse Childhood Experiences (ACE) Study show that young children having a difficult start to their lives can lead to unacceptably high and lifelong, personal, social and economic costs. Members of the 0-2 Group stronglyemphasise that it is crucial to intervene early to promote infant mental health and to reduce the risk of children’s development being hampered by abuse, neglect or other

early parent-child relationship difficulties, thereby reducing the risk of longer termpoor outcomes which incur higher longer term costs.

We need to do more to identify and address needs of those most atrisk of poor outcomes

8. High quality assessment, early years’ intervention and support are vital to giving children

the best start in life and to tackling the underlying causes of ill health and poor wellbeingthroughout people’s lives.

9. The most effective interventions are often those that are preventive instead ofreactive – preventive interventions address risk factors likely to result in future problems for particular families, without waiting for those problems to emerge. Such interventions are also less stigmatising, and can build on both universal screening and provision from midwives and health visitors.

10. Effective action to identify and address the needs of those expectant parents and veryyoung children who are most at risk of poor outcomes can be taken through the full delivery of the Healthy Child Programme and targeted work through children’s

centres, and by ensuring that midwives and health visitors are both resourced andtrained to provide a level of support that promotes sensitively responsive, loving, nurturing parenting and a good two-way relationship and communication between parents and children to promote sound social and emotional development.

The importance of promoting infant mental health and assessing young children’s social and emotional development

11. Health visitors, midwives and other professionals who work with children and theirfamilies are key to better health in the foundation years. Health visitors’ unique skills in

assessing health needs at a population level, at a community level, and at individual child and family level, make them central players in ensuring children develop well and parents and families live happy and healthy lives.

12. Chapter 2 shows the importance of effective assessments of young children’s social and

emotional development. It reinforces the need to continue to reflect what is known about risk factors and times of development, so that health visitors can build on and develop theways in which their practice:


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o identifies risk factors in families as quickly as possible;o promotes infant mental health (emotional wellbeing) ;o assesses young children’s social and emotional development, so that those who appear

to be developing sub-optimal attachments can be identified very early on, and the family’s potential need for targeted, evidence-based interventions is considered and addressed; and

o supports parental psychological health and parenting capacity.

13. The group set out a range of factors which the Department of Health can consider when undertaking any future revision of guidance for health visitors and midwives on developmental reviews as part of the Healthy Child Programme.

The importance of high quality early years’ settings

14. Chapter 2 reviews how to get the most out of universal services to support effective earlyyears’ intervention. Research outlined indicates that the quality of early years’ services

and the settings that younger children and their families experience can have a significantimpact on their outcomes. The quality of settings very much depends on the quality of training and development support available to, and undertaken by, those staff working in them. The chapter proposes priorities for training and development arrangements concerning workforce core skills, knowledge and models of effective supervision, to help inform how the Department for Education might respond to similar themes raised in theNutbrown review.

The economic case for investing in the early years

15. Chapter 3 demonstrates that evidence-based and well implemented preventive servicesand early intervention in the foundation years are likely to do more to reduce abuse andneglect than reactive services and (in the long run) deliver economic and socialbenefits. Such services also have an important role in making sure all children reach school ready to learn and able to achieve to the best of their abilities.

16. A review was conducted of a wide range of published UK and international studies into the economic case for investment in the early years. The consensus from even the mostcautious and circumspect non-UK randomised control trials suggested returns oninvestment on well-designed early years’ interventions significantly exceed both

their costs and stock market returns, with rates of return ranging from $1.26 to $17.92 for every $1 invested. UK studies showed a similar pattern of results: 9 Social Return on Investment studies showed returns of between £1.37 and £9.20 for every £1 invested.

17. Because of poor design or unsuccessful experiment, a small minority of both UK and non-UK early years’ programmes did not deliver a return.

18. In an econometric analysis, Nobel Laureate Professor James Heckman argues that structures (including knowledge and skills) are based on foundations and the stronger thefoundations the more solid the structure, with the highest returns at age 0-3. He also points out that in both promoting economic efficiency and reducing lifetime inequality, early years’ interventions provide policy makers with a rare ability to spend money in a way which simultaneously delivers substantial social and economic benefits.


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19. Scandinavian countries, such as Sweden and Norway, which have adopted whole countryapproaches to investment in early years’ prevention, have achieved not only financialreturns but better health for the whole population. The benefits span lower infant mortality through to reduced heart, liver and lung disease in middle-age.

20. While the Healthy Child Programme (HCP) and the commitment to provide earlyeducation for all disadvantaged 2-year-olds give the UK an existing platform for universal preventive services, there are substantial gaps in early years’ services. Implementation of the HCP is patchy and there is evidence we are not getting early years’ intervention

right, as illustrated by numerous cases of child maltreatment, wide gaps in school outcomes, poor scores in international comparisons of child well-being, high youth crimeand poor health outcomes, making a strong case for improving our investment in priorityareas.

21. One step in this direction has already been achieved by the work of the Under 2s Special Interest Group: as part of their A Better Start initiative, Big Lottery Fund (BIG) is toinvest £165m in prevention-focused early years’ intervention projects in up to fivelocal areas in England, over the coming decade. During the design and set-up of A Better Start the main Under 2s SIG recommendations were discussed in depth with BIG, andplayed a significant part in the outline shape of the core part of their initiative which is intended to promote babies’ and children’s social and emotional development,

language development and nutrition.

22. Historicall , there has been a dearth of reall stro evaluation evidence for earl ears’

interventions in the UK. A ma orward will come with BIG’s A Better Startinitiative, which has set aside a significant sum for evaluation of the success of the 3-5 selected local areas, both in improving outcomes for babies and children and in terms oftheir cost-benefit performance.

23. The key recommendations of the study follow in the next section. In addition, and building on other work on-going in Government, we have developed a framework to provide appropriate support to, and recommendations for, commissioners responsible forstrategy, or early years, at local level (see Local commissioning framework, page 50).


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Recommendations

It is suggested that the following actions could be taken by the noted people or organisations, as ways of building on and improving the promotion of infant mental health – and therebyreducing the long-term implications and costs arising from young children not developingsecure attachment. The recommendations are aimed at Government departments and national organisations and structures. As noted above, a separate framework is set out forcommissioners to use when thinking through the issues to consider in order to provide better support in very early childhood (see pages 50-68).

When responding to the final report from the Nutbrown Review, Departmentfor Education and Department of Health are asked to consider:

i Building modules on child development in pregnancy and early infancy into introductory and in-service training courses to help all practitioners develop awareness of how the first two years of life are critical to a child’s development.

ii Building on and developing in-service training courses to help all practitioners develop awareness of the key factors that promote – and those that can jeopardise –

the positive development of young children, and to understand that behaviour is a form of communication. The importance of considering the emotional, social and health needs of the whole family is key, including the importance of the couple relationship, because these form the context within which the young child is developing. Ideally, this awareness should include:

- key factors during pregnancy- key factors during the first years of life- those factors that promote or can jeopardise infant mental health

(or emotional wellbeing) alongside other aspects of development,

and the promotion of reflective video feedback or Video Interactive Guidance1 as avaluable tool for training both parents and professionals.

iii Encouraging early years’ settings providing quality care for children under age 2 to

have at least one member of staff with additional competence in infant mental health.

iv Setting an expectation that those working in and/or managing early years' settings should engage in professional reflective supervision which supports them in dealingwith the emotionally demanding aspects of their work and building positive, non-judgemental relationships with families. This should also help broaden practitioners’

understanding of the need to demonstrate emotional intelligence in establishing and maintaining meaningful relationships with infants, parents and professional colleagues, even if they themselves come from abusive or neglectful backgrounds.

The Departments for Education and Health are also asked to consider:

v Building on the existing Foundation Years and 4children websites (the EY strategic partner), to collate existing guidance, research and examples of effective and best practice in ways that are more practicable and accessible for practitioners. This would take account of the recent publication of the revised Early Years Foundation StageFramework and the Nutbrown report on qualifications for those working in early


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education and childcare, and the extension of free early education to 40% of two-year-old children. Consult EY sector as part of future reviews to ensure appropriateemphasis is given to the promotion of infant mental health in any further guidance.

vi Consider explicit use of social and emotional assessments when taking forward thecommitment in Families in the Foundation Years to explore options for the integrated review at 2 to 2.5 years of age. Also to continue to consider the timing and frequencyof assessments to follow closely the current NICE guidelines with:

- potential modifications around the timing of the assessment immediately post-partum and the 2-2.5 year integrated review in order to increase validity of the assessment processes.- a universal assessment at 3-4 months to assess the quality of the parent/infant interaction and identify need for additional support to promote parental sensitive responsiveness.- an additional assessment at 12-15 months to assess attachment behaviour, but offered only to Universal Plus or Universal Partnership Plus.

vii As part of the emerging commissioning frameworks, identifying key LA officers and GPs who are willing to act as champions for taking early action to promote infant mental health and address factors that can jeopardise young children’s development –

to help provide models of good practice for the rest of the field.

viii Ask Ofsted and Care Quality Commission to consider whether their inspection frameworks on children’s care and health settings are working to promote infant

mental health sufficiently.

The Department for Education is also asked to consider:

ix Opportunities to influence planning and content for any future parenting publicitycampaign work, in which case we ask that the Department includes messages about the importance of promoting positive parent/child relationships during infancy.

The Department of Health is also asked to:

x Take account of the detailed recommendations in chapter 2, on social and emotional assessments, when revising guidance for health visitors on developmental reviews, as part of the Healthy Child Programme.

xi Include in any guidance to Health and Wellbeing Boards clear information about theimportance of promoting infant mental health and addressing factors that can jeopardise the positive development of babies and young children.

xii Consider the scope for on-going initial health visitor training to be developed so that it includes high quality modules on attachment, specialist pathways, parental and infant mental health, drug and alcohol use, domestic violence, relationships and links to pregnancy, birth and beyond, as core parts of the standardised curriculum.


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The Group findings are relevant to a number of developing policies, particularly:

xiii A key priority is full implementation of the Healthy Child Programme which, over time, would give us a world class programme to reduce the need for additional support for young children and families.

xiv In respect of The New Children and Young People’s Health Outcomes Strategy, wewould like to see:- Very robust early measures, including social and emotional health, and maternal mental health;- The development of the new integrated review at 2-2.5 years;- New input and revisions to the training programmes for health visitors and midwives;- Trials of ICAN parenting classes;- NHS Information Service for Parents;- The revised National Professional Qualification for children’s centre leaders;

- The Government’s response to the Nutbrown report;

- Implementation of the new commitment to provide free early education fordisadvantaged 2 year olds.

xv We strongly endorse the Children and Young People’s Health Outcomes Forum

recommendation that the Department of Health add a new outcome measure (theproportion of parents where parent-child interaction promotes secure attachment in children aged 0-2) to the Public Health Outcomes framework, and suggest our proposed 3-4 month universal assessment would fulfil the recommendation.


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Supporting chapter 1

The importance of child development from conception to age 2

1. This chapter summarises some of the research evidence about factors that can help to promote – or hinder – children’s development before they are born, and then during the

first two years of their lives. It will be demonstrated that child development in the earliest years of life is crucial and fundamental to later outcomes and life chances. In particular, evidence is summarised suggesting that the promotion of very young children’s emotional

wellbeing (sometimes referred to as promoting infant mental health) can be an important foundation for their wider and longer term development.

2. Supporting chapter 2 explains that whilst these messages are fully reflected in the HealthyChild Programme (HCP), the full benefits of this work are reliant on completeimplementation of the programme. Both the HCP and Supporting Families in theFoundation Years are clear that getting the start right is most likely to lead to betterphysical, social, emotional and educational outcomes – from children being school readytowards the end of the Early Years Foundation Stage through to their having improved life chances in the longer term.

3. In supporting chapter 3, we summarise evidence which suggests that the potential longterm benefits of providing appropriate support to very young children who are least likelyto achieve a good level of development can be high compared with the costs of deliveringthese interventions.

Pregnancy

Factors that encourage positive development during pregnancy

4. Evidence summarised below suggests that the best outcomes for both mother and baby, in the period after birth, are most probable in circumstances where mothers are:

o enjoying a well-balanced dieto not experiencing stress or anxietyo in a supportive relationship – and not experiencing domestic violenceo not smoking, consuming alcohol or misusing illegal substanceso not in poor physical, mental or emotional healtho not socio-economically disadvantagedo at least 20 years oldo have a supportive birthing assistant at the birth itself2

Factors that can hamper development during pregnancy

Some causes and longer term effects of low birth weight5. The Marmot Report on health inequalities3 cited evidence that development begins before

birth and that the health of a baby is crucially affected by the health and well-being of themother4,5. Low birth weight in particular is associated with poorer long-term health and educational outcomes6.


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6. Barker has shown that when human foetuses have to adapt to a limited supply of nutrients, they permanently change their structure and metabolism. These ‘programmed’

changes may be the origins of a number of diseases in later life, including coronary heart disease and the related disorders of stroke, diabetes and hypertension7. Evidence suggeststhat maternal health is related to socioeconomic status8, and that disadvantaged mothers are more likely to have babies of low birth weight9. Smoking, maternal stress, and arelative lack of pre-natal health care, maternal nutrition and maternal education have also been reported to be associated with low birth weight10.

7. In more than 50 published studies, Eriksson et al report that raised blood pressure in laterlife has been found to be associated with low birth weight and that this is due to retarded foetal growth rather than premature birth11. Barker suggests that foetal under-nutrition in middle to late gestation can result in disproportionate foetal growth, later high blood pressure and coronary heart disease12.

8. Low birth weight is also associated with reduced child development13,14 and educational attainment15. For example, using the British National Child Development Survey, Currie and Hyson16 found that children weighing less than 2,500 grams were more than 25% less likely than others to achieve what were then O-levels in English and Maths, and were less likely to be employed at age 33.

9. There can also be long-term difficulties associated with very high birth weight. Oken and Gillman17 report that babies born at the high end of the weight spectrum have higher Body Mass Indices as adults and are at higher risk for obesity and type 2 diabetes.

Smoking during pregnancy10. Smoking during pregnancy is associated with a range of serious infant health problems,

including lower birth weight (which itself is associated with poorer long term outcomes, as summarised above), and perinatal mortality18. In addition, smoking during pregnancyhas been associated with poor child behaviour at age 519.

11. Compared with other mothers, deprived mothers are more likely to smoke. However, babies from all backgrounds are at risk from problems that can arise if their mothers smoke during pregnancy.

Drug misuse in pregnancy12. Maternal misuse of drugs during pregnancy increases the risk of low birth weight,

premature delivery, perinatal mortality and cot death20. The risks and dangers depend on the pharmacological make-up of the drug, the gestation of pregnancy and the route, amount and duration of drug misuse.

13. Structural damage to the foetus is most likely during 4-12 weeks of gestation; drugs taken later can affect growth or cause intoxication or withdrawal syndromes21.

Drinking alcohol during pregnancy14. A number of risks are associated with drinking alcohol during pregnancy22, including:

o Increased risk of miscarriageo Risk of Foetal Alcohol Syndrome (FAS) whose features include: growth deficiency

for height and weight, a distinct pattern of facial features and physical characteristics and central nervous system dysfunction


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o Risk of Foetal Alcohol Spectrum Disorders (FASD) – which do not show the full characteristics of Foetal Alcohol Syndrome and develop at lower levels of drinking

o Increased risk of learning disability (without either of the above conditions)

15. Internationally, there is wide agreement on the diagnostic criteria for the full Foetal Alcohol Syndrome, but not on diagnostic criteria for FASD. A National Perinatal Epidemiology Unit (NPEU) review of evidence23 on the effects of prenatal alcohol exposure discussed the difficulties of identifying accurately children with Foetal Alcohol Syndrome and alcohol-related neurodevelopmental disorders, and the resultingdifficulties in estimating prevalence. The review considered the risks of foetal exposure to low to moderate alcohol consumption and to binge drinking during pregnancy. It foundno consistent evidence of adverse effects from low-to-moderate prenatal alcohol consumption, although it was noted that the evidence base is limited.

16. Research by Abel24 in USA suggests that while most women who drink heavily duringpregnancy give birth to healthy babies, 4 per cent of them have babies with FASD. Prenatal alcohol exposure has also been associated with increased risk of conduct disorder in adolescence25.

Maternal depression and stress during pregnancy17. The emotional state of the mother during pregnancy – in combination with smoking, and

misuse of alcohol and drugs while pregnant – has been reported to be associated with thechild’s later development of antisocial behaviour

26. For example, antenatal anxiety at 32 weeks’ gestation has been linked to behavioural and emotional problems in the child at age 4 (even after a range of controls including postnatal anxiety)27,28

– compared to other children, those of mothers in the top 15% for anxiety were at double the risk foremotional or behavioural problems, including ADHD and conduct disorder. A factor potentially related to stress during pregnancy is that having a baby or experiencing amiscarriage can put extreme pressure on relationships29.

Domestic violence18. A number of studies suggest there can be an increased incidence of domestic violence

during or shortly following pregnancy. For example, a survey of 1,207 women attendingGP surgeries in Hackney found that pregnancy in the past year was associated with an increased risk of current violence30.

19. Overall, it is important that those providing services to pregnant women are aware of potential risks to mothers’ and babies’ welfare and development, and identify where theserisks are heightened. Some of the implications for service commissioning and practice areexplored in Chapter 2 of this report.

Positive development

Factors that encourage positive development from birth to age 2

Overview20. Evidence is clear that after a child has been born, physical health is promoted through

good nutrition (breastfeeding is a particularly important factor) and immunisation, and that physical and emotional health are interlinked and interdependent. For very youngchildren, secure relationships (i.e. parenting which initially is highly sensitive andresponsive to the baby’s signals and cues) promote emotional health (sometimes referred


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to as positive infant mental health) and have a direct effect on later emotional, social and physical health, both in childhood and in the longer term. Secure relationships also haveeffects on cognitive development, language development and other learning.

21. Good quality relationships and secure attachment enable a growing brain to become socially efficient, so providing a basis for future self-control and cognitive development. Much of the baby’s environment – from the baby’s point of view – consists of relationships with his or her parents or carers. The quality of this environment influences the development of the brain and social behaviours in ways that form a foundation for thechild’s future experiences and his or her responses to them.

22. Evidence summarised below suggests that the quality of the parent/child relationship flows from the way in which parents are looking after, caring for and responding to their young child. As children become 3 years and older, the Effective Provision of Pre-School Education (EPPE) study demonstrates that those who experience a good early years homelearning environment, a good quality pre-school and a more effective primary school aremore likely to show improved cognitive and social outcomes compared with children who have two, one or none of these experiences31,32.

23. In EPPE, the home learning environment was measured by the extent to which parents take part in learning activities with their children – including reading to them, playingwith letters and numbers, taking them to the library, painting and drawing, teaching them nursery rhymes and songs, taking them on visits, and arranging for children to play with their friends at home33,34,35. While these measures were devised for children aged threeand over, other evidence (summarised later in this chapter) relating to languagedevelopment demonstrates that a good home learning environment is important forchildren who are younger than this – as part of parents’ overall care for their very youngchildren.

Breastfeeding and nutrition24. Optimal infant nutrition, especially breastfeeding, is a protective factor for the health of

babies and mothers. It increases children’s chances of leading a future healthy life. For

both the mother and child, breastfeeding can reduce such potential health risks as gastroenteritis, respiratory disease, and obesity in later childhood36,37,38.

25. The association between breastfeeding and child cognitive development in term and preterm children has been researched by analysing data on children from the Millennium Cohort Study. Children were grouped according to breastfeeding duration and British Ability Scales tests were administered when they were 5 years old. After adjusting forother variables (e.g. smoking, social class, maternal education), there was a significant difference between children who were breastfed and those who were never breastfed. Overall, breastfed children were one to six months ahead of those who were never breastfed39.

Immunisation26. There is a clear public health case for the Healthy Child Programme’s recommended

immunisations, and this underpins NICE’s 2009 guidance entitled Reducing differences in the uptake of immunisations (including targeted vaccines) among children and young people aged under 19 years40. The guidance cites evidence that differences in uptakepersist and are associated with a range of social, demographic, maternal- and infant-


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related factors. In particular, the guidance says that the following groups of children and young people are at risk of not being fully immunised:

a. those who have missed previous vaccinations (whether as a result of parental choice or otherwise)

b. looked after childrenc. those with physical or learning disabilitiesd. children of teenage or lone parentse. those not registered with a GPf. younger children from large familiesg. children who are hospitalised or who have a chronic illnessh. those from some minority ethnic groupsi. those from non-English speaking familiesj. vulnerable children, such as those whose families are travellers, asylum seekers or

homeless.

27. The guidance also notes there are some groups of children who are less likely than others to have received certain vaccines, even though they have had some.

The importance of parenting and the parent-child relationship28. Evidence suggests that parenting behaviour and the quality of the parent-child

relationship are strongly associated with children’s outcomes. For example, loving,

authoritative and responsive parenting is important for building resilience and preventingchildren developing behaviour problems41,42,43,44.

29. Effective loving and authoritative parenting gives children confidence, a sense of well-being and self worth. It also stimulates brain development and the capacity to learn. Parents who develop ‘open, participative communication, problem-centred coping, non-punitive patterns of parenting and flexibility’ tend to manage stress well and help their

families to do the same45.

30. In contrast, harsh, negative or inconsistent discipline, lack of emotional warmth or supervision and parental conflict all increase the risk of emotional and behavioural problems that can lead to anti-social behaviour, substance misuse and crime46.

31. Higher levels of maternal depression are associated with such adverse outcomes in infancy and early childhood as language and cognitive deficits and behavioural problems47,48,49. Maternal depression can diminish children’s wellbeing, partly as a result

of less nurturing and less engaged parenting (e.g. more use of harsher disciplinarypractices, less play, less eye contact and less time reading). This has been linked with greater behavioural problems among children such as aggression, acting out, withdrawal and anxiety. It is also suggested that antenatal maternal depression is associated with an increased risk of offspring being subjected to childhood maltreatment. The association between antenatal depression and offspring psychopathology is due only to the high prevalence of depression and conduct disorder in children exposed to both antenatal depression and childhood maltreatment – not in those with either one or the otherexposure50.

The importance of the relationship between parents32. Parenting is about fathers or other co-parents (such as partners who are not the child’s

father and other care givers such as grandparents) as well as mothers. It is therefore


15

important to look beyond those studies that focus only on the relationship between mothers and their young children, because these do not cover the whole picture. Forexample, the strength of the relationship between parents, as well as relationships between children and their parents, can have a significant impact on young children’s

development.

33. A review of evidence51 suggests that children raised by parents reporting a positive relationship quality and satisfaction tend to have high levels of wellbeing. Intensedestructive conflict between parents has been shown to be more detrimental to children than the event of separation itself. A survey of school children found that family conflict had the strongest association with child unhappiness, and simple measures of how families were getting along were able to explain 20% of the variation in children’s

subjective well-being52.

34. Studies also identify a number of protective factors that can minimise the effects of children’s adjustment to family breakdown. These include competent and warm parenting, parents’ good mental health, low parental conflict, cooperative parenting post

separation and social support53.

35. Having a baby, experiencing a miscarriage, juggling the demands of work and childcare, ill health and money worries can put extreme pressure on relationships54. Other factors that heighten the risk of relationship breakdown include parents being on a low income(especially if they are not married), couples where either or both partners have been married before or where either of them had childhood experience of parental divorce, and where couples marry at a relatively young age. It has also been found that parents of disabled children are at greater risk of relationship problems and divorce55.

Three interlinked key areas of young children’s development –brain, attachment and language36. The brain is developing rapidly during the first few years of a child’s life. Neurological

research indicates that neurons and the connections between them change in response to external signals, enabling the brain to respond to new experiences and thus develop further56,57,58. The developing brain of the baby adapts itself to the quality of therelationship with parents and the home learning environment, creating neural circuits that mirror his/her experiences59,60,61,62,63.

37. The care-giving environment during the early years is also fundamental to children’s

development of secure emotional attachment. Bowlby64 described how infants become securely attached to adults who are consistently sensitive and loving and predictable in social interactions with them. With the security of knowing that the primary caregiver is emotionally available, the child grows in confidence to explore the surrounding world, including the learning opportunities of nursery and school.

38. Ainsworth et al65 reported that infants of mothers demonstrating higher levels of sensitivity were more likely to show secure attachment behaviour when a year old. High sensitivity was found to be associated with more acceptance, cooperation, and accessibility in mothers’ interactions with their infants.

39. Some (but certainly not all) of the risk factors known to affect adversely the parent-babyrelationship are: such problems intrinsic to the baby as low birth weight or disabilities; a


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parent who lacks the ability to attune sensitively to the baby’s needs; a parent who does not interact with or who maltreats the infant; one or both parents struggling with a mental health or addiction problem, or with a background of abuse, neglect or loss in their own childhood; parents with inadequate income or sub-standard housing; family dysfunction and/or experiencing domestic violence; or being a single teenage mother without support66,67,68,69,70,71.

40. Barlow and Svanberg72 cite a wealth of international research evidence73,74,75,76,77,78 that approximately 35-40% of all parent-infant attachments are sub-optimal.

41. Fearon et al79 undertook a rigorous meta-analysis of over 60 studies (most of which werelongitudinal) that had looked at associations between attachment and behaviour. Overallthey concluded that:

a. attachment that is not secure in infancy – particularly for boys – is associated with externalising behaviour problems (e.g. aggression) later in childhood;

b. the association was found to be slightly higher for those with disorganised attachment – various studies following up infants with disorganised attachment have found elevated risks of aggressive behaviours, mental disorders, school behaviour problems and other psychopathologies80,81,82,83;

c. the studies included in Fearon et al’s analysis were judged to demonstrate

associations between sub-optimal attachment and externalising behaviour problems, not causation;

d. socio-economic status did not strongly affect the link, suggesting that higher income is not protective if a child does not have secure attachment;

e. the association did not wash out over time – indeed there were indications it grew stronger;

f. the more rigorous and impartial the method used in a study (e.g. observed ratherthan reported behaviour), the stronger the association seemed to be.

42. There are also research findings indicating that the circumstances in which disorganised attachment is more likely to arise are also circumstances in which children are more likelyto develop later difficulties. For example disorganised attachment is more likely to arisewhere:

a. parents have serious affective disorders, including depression84 - and it is reported that the children of mothers with mental health issues are twice as likely to experience a childhood psychiatric disorder85,86,87;

b. parents are maltreating their children88. It is reported that around 80 per cent ofmaltreated infants have disorganised attachment89

– and there is considerable evidence of the long-term effects of maltreatment, summarised later in this Chapter. However, by no means have all children with disorganised attachment been maltreated;

c. parents are involved in domestic violence90 - it is reported that around 25% of children witnessing domestic violence develop serious social and behavioural problems91;

d. parents are dependent on alcohol92 or are heavily misusing hard drugs93. There is evidence that there is heightened risk of emotional unavailability and/or abuse and neglect in these circumstances94,95,96.


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43. Each circumstance cited above is an example of factors in families’ lives that can impair

the quality of the parent-child relationship. It can be seen from these examples that wherethere are difficulties in the parent-child relationship, it is more likely there will beattachment difficulties and poorer future life chances. It is where there is abuse or neglect that there is the greatest probability of poor outcomes for the child.

44. Good quality relationships and secure attachment enable a growing brain to become efficient and so provide a basis for future self-control and cognitive development, whereas a brain developing in the context of maltreatment will carry into later years what were once necessary responses to a hostile environment. A paper from Harvard University’s National Scientific Council on the Developing Child

97 explains that completing most tasks requires the successful orchestration of working memory, inhibitory control, and cognitive or mental flexibility. The paper cites evidence that exposure to highly stressful early environments is associated with deficits in thedevelopment of these skills.

45. An earlier paper98 cites studies indicating that, without access to support from caringadults, young children’s responses to stressful events can have an adverse impact on brain architecture. Newborn babies have been found to respond to stress by producing high levels of the stress hormone cortisol but, where they are cared for sensitively and responsively, the levels usually lessen. It has been suggested that elevated levels of such stress hormones as cortisol can be harmful to brain development, especially duringinfancy99.

46. The early years are also when language is being acquired, hence the importance of providing an environment rich in spoken language. Research100,101,102,103,104,105 shows that, from birth, children’s learning results from their interaction with people and their

environment. Children need a natural flow of affectionate, stimulating talk, to describewhat is happening around them, to describe things that they can see, and to think about other people. This is critical for children’s language and cognition, their general capacity

to engage with new people and new situations, and their ability to learn new skills.

47. Children begin to recognise sounds, and associate them with objects and ideas, within sixmonths of birth. The brain translates sounds into language, but to do so effectively itneeds input from the social world, in the form of positive and warm interaction with adults.

48. Language development at age two is very strongly associated with later school readiness, with the early communication environment in the home providing the strongest influenceon language at age two – stronger than social background. The number of books available to the child, frequency of visits to the library, being read to by a parent, parents teaching arange of activities, the number of toys available and attendance at pre-school are allimportant predictors of two-year-old children’s vocabulary

106.

49. As children grow older, vocabulary at age five becomes the best predictor of later social mobility for children from deprived backgrounds107. Evidence from the MillenniumCohort Study indicates that, at this age, children from the most advantaged groups wereover a year ahead in vocabulary, compared to those from the most disadvantaged backgrounds108. An earlier American study109 found that, by the age of three, children from privileged backgrounds have heard around 30 million more words than children


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from underprivileged backgrounds. The amount of time and energy that parents and carers invest in home learning varies greatly from family to family. For example, evidence shows that parents with lower qualifications engage less frequently than better educated parents in some home learning activities, such as reading110,111,112.

50. The EPPE (Effective Provision of Pre-school Education) Project indicates that programmes which directly promote activities in which parents and children can engagetogether are likely to be beneficial for young children113

. Children’s centre stay and play

or family learning sessions can be examples of such activities.

51. It can be seen that some groups of very young children are more likely than others to experience factors that promote or hamper their language development.

Some children are more likely than others to experience factors that hamper their development, and it is important to focus on the prevalence of this.

52. Poor maternal mental health and well-being at age nine months and/or at three years is strongly associated with poor child behaviour at age five. 10 per cent of mothers arereported to experience post-natal depression114. As already noted above, it is reported thatthe children of mothers with mental health issues are twice as likely to experience achildhood psychiatric disorder115,116,117.

53. Parental mental illness (including substance misuse), particularly in the mother, is also associated with: poor birth outcomes118, increased risk of sudden infant death119 and increased child mortality120. Post-natal depression and other forms of mental illness arelinked to an increase in insecure attachment in toddlers, behavioural disturbance at home, less creative play and greater levels of disturbed or disruptive behaviour at primaryschool, poor peer relationships, and a decrease in self-control with an increase in aggression121,122,123,124,125.

54. Prolonged and/or regular exposure to domestic violence can have a very serious impact on children’s safety and welfare and it rarely occurs in isolation. Parents may also misusedrugs or alcohol, experience poor physical or mental health or have a history of poor childhood experiences themselves. Domestic violence impacts on children in a number of ways126: they are at risk of physical injury during an incident, they can experience serious anxiety and distress which can express itself in anti-social or criminal behaviour – and domestic violence can also impact on parenting capacity and attachment. There is also research evidence indicating that children who have been exposed to domestic violenceare more likely to be abused themselves than those from non-violent households. Research shows that children who have been exposed to domestic violence are 158%more likely to be abused themselves than those from non-violent households. The risk is115% higher for boys & 229% higher for girls127.

55. Parental drug dependence is generally associated with some degree of child neglect and emotional abuse, parents having difficulty in organising their own or their children’s

lives, parents having difficulty meeting children’s needs for safety and basic care, parents

being emotionally unavailable, and/or parents having difficulty in controlling and disciplining their children128,129. In England and Wales it is estimated that one per cent ofbabies are born each year to women who are misusing opiates or crack cocaine and that two to three per cent of children under 16 have parents who are doing so. Only about a


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third of fathers and two-thirds of mothers who are misusing opiates or crack cocaine arestill living with their own children130.

56. The risks associated with parental alcohol misuse are more likely to be connected with violence and physical abuse if the father is misusing alcohol. If the mother is misusingalcohol, children in the family are more likely to experience neglect131. Adverse effects of parental alcohol misuse are most likely when there is violence, family discord ordisorganisation.

57. Young children whose parents misuse alcohol can be at risk of significant harm, becauseparents may fail to notice, respond to or engage appropriately with their baby, which mayresult in insecure attachment; lack of concentration can lead to a mobile child not beingkept safe from harm; parents may not notice when the baby is unwell; parents may not respond to children’s need for food because alcohol consumption suppresses hunger;

parents may be unable to respond to the child’s emotional and cognitive needs and

development; and there might be insufficient income and poor physical standards in the home132.

58. A recent 2012 report from the Royal College of Physicians quantifies the damage that can be experienced by children who are growing up in households where someone (usually aparent) is smoking. The report estimates that every year in the UK over 20,000 cases of lower respiratory tract infection, at least 22,000 new cases of wheeze and asthma and 120,000 cases of middle ear disease are caused by passive smoking in children; and that around 23,000 young people per year take up smoking before the age of 16 as a result of exposure to smoking by others in the household133.

59. There is research evidence indicating that experiencing low socio-economic status at both 9 months and 3 years is associated with increased likelihood of poor behavioural, learningand health outcomes at age 5. These associations are stronger where the experience was persistent at both time points rather than being single episodic experiences134. There is a two to three fold increased risk in the onset of emotional/conduct disorder in childhood if children have an unemployed parent135 and a three-fold risk of mental health problems (15% compared to 5%) if children are in families with lower income levels136. Further evidence on associations between socio-economic status and longer term outcomes has been summarised by the University of Sheffield in a series of evidence reviews commissioned by the National Institute for Health and Clinical Excellence (NICE) to support preparation of draft guidance on promoting social and emotional wellbeing in theearly years137.

60. DfE’s Statistical First Release (SFR) 29/2011 – entitled Early Years Foundation StageProfile Attainment by Pupil Characteristics in England, 2010/11 – showed that the percentage of children achieving a good level of development in 2011 at age 5 was 59% (compared to 56% in 2010). However:

o Girls outperformed boys with 68% of girls achieving a good level of development compared to 50% of boys.

o A higher proportion (60%) whose first language is English achieved a good level of development compared with others (52%).

o 44% of those eligible for free school meals (FSM) achieved a good level of development compared with 62% of others (either not eligible for FSM or unclassified).


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61. These and similar research findings do not mean that every young child growing up in relatively advantaged circumstances will automatically experience positive development, or will never experience risks to their development, nor that children facing manydisadvantages are prevented from achieving good outcomes. What the findings do mean, however, is that young children facing various disadvantages are less likely than others to experience positive development. Such disadvantages are sometimes called ‘risk factors’.

62. The association of poor development with several risk factors together can be stronger than its association with a single risk factor. For example, the Millennium Cohort Study(MCS) demonstrates correlations between income group and parenting with thelikelihood of achieving good development by age five. The percentage of each of thefollowing groups of five year olds in the MCS sample whose Foundation Stage Profileassessments showed good development were as follows138:

a. No Poverty and Positive Parenting 73%b. No Poverty and Poor Parenting 42%c. Persistent Poverty and Positive Parenting 58%d. Persistent Poverty and Poor Parenting 19%

No Poverty Persistent Poverty Impact ofPersistent Poverty

Positive parenting 73% 58% -15%Poor parenting 42% 19% -23%Impact of poorParenting

-31% -39% -19%-35%

63. The table above shows that, on average, poor parenting had nearly double the impact of persistent poverty. In the study, on average, good Foundation Stage development at age 5 was depressed by 19% by Persistent Poverty and by 35% by Poor Parenting.

64. It can be seen that the combination of persistent poverty and poor parenting had astronger association with poor development (than either poverty or parenting in isolation).

65. However, risk factors often do not exist in isolation; they come together around individual families. Poverty, unemployment, lone parenting, having a large family, poor orovercrowded housing, having a difficult child, parental illness and substance misuse, can have a negative impact on parenting. In combination, the factors are linked and mutuallyreinforcing139.

66. Children from families with multiple problems often have very poor life chances indeed, which becomes especially apparent when they are in their teens. Research evidenceshows that children aged 13-14 who live in families with five or more problems are 36 times more likely to be excluded from school than children in families with no problems, and six times more likely to have been in care or to have contact with the police140.

67. A report by Sabates and Dex141 quantifies the prevalence of multiple risks for familieswith very young children in the UK, including by ethnicity. It also examines the associations of multiple risks to deficits in developmental outcomes at three and fiveyears of age. The ten risk factors considered were: living in overcrowded housing; havinga teenage mother; having one or more parents with depression, a physical disability, or


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low basic skills; substance misuse; excessive alcohol intake; and living in a familyexperiencing financial stress, worklessness or domestic violence.

68. Using MCS data, it was demonstrated that 28 per cent of families with young children across the UK in 2001 were facing two or more of these risks (an estimated 192,000 children under a year old). Less than two per cent of children were exposed to five or more risks. Just over four in ten children did not experience any of these risk factors in early childhood. A further three in ten faced only one.

69. Children facing two or more risk factors had poorer behavioural development scores at ages three and five than those experiencing one or no challenges. The vocabulary scores of the children with multiple challenges were also lower and they fell further behind between ages three and five. Children in families with both multiple risk factors and low income fared worst across most developmental outcomes. There was no dominant pattern of risks. For example, for families facing three risks, the most common combination was smoking during pregnancy, financial stress and teenage motherhood. However, this combination applied to only six per cent of families living with three risks. Parental depression was the most prevalent factor overall.

70. It follows that:

o The knowledge of risks enables commissioners and practitioners to consider targetingintervention to particular groups before something goes wrong (when it is preventive) rather than when it has occurred (when intervention is reactive).

o Services need to be able to respond flexibly to a variety of risk patterns. Sure Start Children’s Centres have a crucial role to play to ensure parents are able to parent well by helping them cope with or avoid other stresses. Following findings from theNational Evaluation of Sure Start (NESS), children’s centres should focus more

keenly on this aspect of their role, and draw on evidence of what is effective much more rigorously.

Long-term effects of adverse experiences in children’s early years

71. For some children, risk factors translate into catastrophic consequences very early on. The NSPCC’s recent report All Babies Count emphasises that such risk factors as parental mental illness, substance misuse and domestic abuse are not determinants of child abuse; however, they elevate the likelihood that it might be occurring. The report cites evidencethat:

a. 45 per cent of serious case reviews in England relate to babies under 1 year oldb. in England and Wales, babies are more likely to be killed than older childrenc. in the UK overall, an estimated 19,500 babies under a year old are living with a

parent who has used Class A drugs in the last yeard. in the UK overall, 39,000 babies under a year old live in households affected by

domestic violence in the last yeare. in the UK overall, 93,500 babies under a year old live with a parent who is alcohol

dependent; andf. in the UK overall, 144,000 babies under a year old live with a parent who has a

common mental health problem.

72. In Learning lessons from serious case reviews 2009–2010, Ofsted looked at 147 reviews from April 2009 to March 2010. Over this period, 194 children were involved, 69 of


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whom were under a year old, and of the 90 children who died, 36 were infants. The mostcommon issues were mental ill-health, domestic violence and drug and alcohol misuse. Frequently more than one of these characteristics was present. Their follow-up report, published in 2011, Ages of concern: learning lessons from serious case reviews, reiterated that a large proportion of reviews concerned babies less than a year old (along with youngpeople aged 14 and over). The report also summarised the following recurring messages about the handling of these babies’ cases:

a. there were shortcomings in the timeliness and quality of pre-birth assessments;b. the risks resulting from the parents’ own needs were underestimated, particularly

given the vulnerability of babies – parental needs often related to drug or alcohol misuse, a past history of being looked after, abuse they had suffered during theirown childhoods, or being involved in domestic violence as an adult. Poor parental mental health and unstable lifestyles were also identified as key risk factors in some cases;

c. there had been insufficient support for young parents;d. the role of fathers had been marginalised;e. there was a need for improved assessment of, and support for, parenting capacity;f. there were particular lessons for health agencies, whose practitioners had been the

main or only agencies involved with the family in the early months – for example, ensuring sufficient communication about potential risks among various practitioners involved; and

g. practitioners underestimated the fragility of the baby.

73. For young children who survive abuse or neglect, there can be longer term negativeoutcomes. For example, Read et al142,143,144 cite studies demonstrating that child abuse has a causal role in most mental health problems, including depression, anxiety disorders, eating disorders, substance misuse, personality disorders, and dissociative disorders.

74. Similar findings emerged from the Californian Adverse Childhood Experiences (ACE)Study145 which looked at correlations between long-term health conditions and the following self-reported early adverse experiences:

a. Physical abuse – beatingb. Physical neglectc. Emotional neglectd. Contact sexual abusee. Mother treated violentlyf. Household member was misusing alcohol or drugs g. Presence of mental illness h. Parental separation or divorce – not raised by both biological parentsi. Incarcerated household memberj. Emotional abuse – recurrent humiliation

75. It was found that the more of these adverse experiences were reported, the greater thelater incidence of:

o Smoking, fractures, severe obesity, alcohol and drug misuseo Ischaemic heart disease, stroke, chest diseases, cancero Diabetes, hepatitis, sexually transmitted diseases, ando Depression, attempted suicide


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76. Exposure to traumatic circumstances in early childhood has also been found to be associated with lower cognitive development. The Minnesota Longitudinal Study of Parents assessed the cognitive development of young children in a sample of participatingfamilies, alongside observations of mother-child interactions, interviews with the mother, and reviews of medical and child protection records. It was rated whether a child was being abused or neglected or had witnessed domestic violence, and their intellectual development was also assessed at the ages of 24, 64 and 96 months. Comparisons of thefindings indicated that children who had been maltreated or who had witnessed domesticviolence had lower scores on the cognitive measures at all time points, including when the analysis was controlled for socio-demographic factors, mother’s IQ, weight at birth,

birth complications, the quality of intellectual stimulation at home, and gender146.

Concluding note

77. As Michael Marmot said in his report on health inequalities147:

‘The foundations for virtually every aspect of human development – physical, intellectualand emotional – are laid in early childhood. What happens during these early years (starting in the womb) has lifelong effects on many aspects of health and well-being.’

78. This supporting chapter has summarised some of the research available showing the wideranging influences on very young children’s development, both before they are born, and during the first two years of their lives. In particular, we have seen how very early child development can be fundamentally affected by the relationship between each child and his or her primary caregiver. In turn, that relationship is likely to be affected by factors in the caregiver’s wider environment – especially (but certainly not only) if she or he is experiencing mental illness or domestic violence, and/or if she or he is misusing drugs or alcohol. It is vital that agencies work together as set out in the revised Working Together to Safeguard Children148 in all circumstances where a child is considered to be at risk of abuse or neglect, including if there are concerns that a child’s health or development

might be at risk of being significantly impaired without the provision of additional services.


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Making best use of resources for 0-2s

1. In this chapter, we review:

o how to get the most out of universal services to support approaches to earlyintervention in ways that build on families’ strengths and involvement, while tackling

the risk factors likely to hamper very young children’s development;

o how we could get the most out of effective social and emotional assessments as part of the full HCP offer;

o importance of training and qualifications in the Healthy Child Programme (HCP) and Early Years (EY) workforces.

2. The Marmot Report149called for ‘proportionate universalism’ to address health

inequalities – actions that are universal, but with a scale and intensity proportionate to need. In practice, this involves making services available for everyone, with additional services for those with greater needs. Sure Start Children’s Centres explicitly take this

approach in most areas, and this is reflected in their stated core purpose150.

3. In their review of evidence on early intervention, Statham and Smith151 note that usually a distinction is made between services that are available to all – universal services, and those provided for groups which may need specific help or preventive support – targeted services. In addition, there can be specialist services for those individuals or families with the most complex needs.

Getting the most out of universal services

4. It is through universal services such as midwifery, GP surgeries, children’s centres, health

visitor home visits, and childcare and early education settings, that practitioners see allfamilies with young children from time to time. As suggested in Supporting Families in the Foundation Years, these services provide opportunities, when families are already in contact with professionals, to assess their needs and to offer further help where it’s

needed and as early as possible to prevent or tackle emerging problems.

5. For instance:

o midwives152 and health visitors can promote positive parenting and good parent/child relationships from the outset, and link families to wider resources through children’s

centres;o family support workers and outreach teams based in Sure Start Children’s Centres can

identify and support the most vulnerable families very early in a child’s life;o professionals in adults’ services including social care, the NHS, housing and

Jobcentre Plus, can ‘think family’153 and consider what support parents might need

with fulfilling their parenting role when they are addressing such issues as parental mental illness, substance misuse, past maltreatment or domestic violence.

6. It is important that all practitioners have an awareness of the risk factors that can jeopardise child development, particularly infant mental health (i.e. the factors that can jeopardise early attachment and brain development). In particular, practitioners need to beaware of the need to consider the emotional, social and health needs of the whole familybecause these form the context within which the young child is developing154. Early


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identification enables those working in universal services to offer these families earlyhelp, either by offering additional help themselves, or by referring families to targeted orspecialist services.

Making the most of children’s centres: integrated services

7. There are Sure Start Children’s Centres in every local authority area. They help families and expectant parents access universal services, and provide a welcoming environment for many families in need of extra support. They refer families to targeted or specialistservices where appropriate and often provide them on site.

8. Children’s centres’ core purpose makes clear that they are for everyone, but they should

be doing progressively more in a targeted way for those families who have the most needs – to improve wellbeing and reduce inequalities. They offer support for children and families who experience multiple risk factors, or children in need (section 17 of the Children Act 1989), plus they can model a child and family-centred approach to accessingwider specialist support. This requires children’s centres to make good links with specialist services (e.g. social workers and/or family intervention services) to identifyfamilies and to be part of an integrated package of support. It also requires local authorities to be clear about thresholds for using systems like the Common Assessment Framework or to refer to a family intervention service or to statutory social care services, so that centres can refer families appropriately.

9. This integrated one stop shop approach has proven popular with users. Research evidenceindicates that parents value services that are co-ordinated, so that information is shared and does not have to be repeated several times155. An integrated approach is also veryimportant for the most vulnerable families suffering multiple risk factors and needing a range of different support – which chapter 1 showed are the groups who are extremelylikely to suffer poor outcomes. Children’s centres are very well placed to bring together

services around individual families in non-stigmatising ways that involve and empower the family.

10. Evidence suggests that early intervention by midwives or other health engagement at children’s centres can lead to a direct reduction in young children's risk of poor outcomes156 including:

a. reduced incidence of low birth weight and of foetal and postnatal injuryb. improved uptake of preventive health carec. a lower risk of poor bondingd. reduced child neglect and abuse

11. There are already many examples of health visitors and children’s centres working

together. Below are examples of integration157 which illustrate the benefits of an integrated approach in delivery of better outcomes for those who access and use services at a local level and strategically across a local authority area.


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Integrated working between a health visiting team and a children’scentre: The Chai Centre, BurnleyIn The Chai Centre the health visiting team and the children’s centre team share an

office and co-location makes communication easier. To step across an office and talk to someone is simple; leaving messages which are returned when you are out is alaborious process.

Sharing records was a major hurdle. It took time and training to get this right, but the team now have just one set of records for each child.

The teams developed an enhanced version of the Healthy Child Programme, with every family receiving 12 core home visits in the first three years of life. These areenhanced by bespoke packages of care being jointly delivered to families with assessed additional needs.

Health visitors and children’s centre workers do some joint visits, particularly wherethe issues are more complex. Where children’s centre workers provide family support,

the health visitor is always fully informed and provides on-going guidance and support to the worker.

Outcomes:o Safeguarding issues are less likely to fall through a gap and problems are spotted

sooner for early intervention.o CAFs are completed holistically and efficiently with ‘team around the child and

family’ meetings being hosted jointly.o Health visitors have helped children’s centre staff develop their skills and the

children’s centre team has helped health visitors by delivering on-going support to families with lower levels of need and working effectively in an ethnically diversearea.

o The intensive outreach programme led to a dramatic increase in families accessingservices at the centre and very high levels of engagement are maintained.

o Integrated working has allowed the teams to use the mix of skills effectively –

o families are supported by the worker with the right skills and knowledge for them, freeing health visitors to concentrate on the most complex issues.

Health visitor led children’s centres: Brighton and Hove Children’sCentresIn Brighton and Hove, children’s centres are managed as a city-wide service, led bythree Neighbourhood Sure Start Service Managers, two with health visitor backgrounds and one from social work. The entire health visiting service for the cityhas been seconded into the Council and works as an integral part of the Children’s

Centre service.

The integrated children’s centre teams are led by health visitors who supervise out-reach workers. Specialist city wide teams offer specific support, for examplebreastfeeding coordinators to encourage initiation and sustain breastfeeding in areas of the city where this is low. Traveller and asylum seeker families are supported by aspecialist health visitor and early years’ visitor. Teenage parents are supported by

named health visitors at each children’s centre and by early years’ visitors.


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Outcomes:This model has delivered value for money and safe, evidenced-based health caredelivery. The impact is seen in improved breastfeeding rates, obesity rates in reception and a sharp rise in the percentage of children living in the mostdisadvantaged areas who achieve a good Early Years Foundation Stage Profile score –

from 33% in 2008 to 55% in 2011. Key developments include focusing support on themost disadvantaged families and increasing the use of evidence-based programmes,including Family Nurse Partnership. The most recent children’s centre to be inspected by Ofsted was judged to be outstanding in every area, and it noted that the health-led model plays a fundamental part in streamlining services and integrating provision. Ante-natal and post-natal services are delivered directly from the centre. As a result, the centre reaches 100% of children aged under five years living in the area. Highlyeffective intervention by the centre’s health partners has made an impressive impact

on children’s welfare and family well-being.

12. Whilst most children’s centres already provide a range of evidence-based programmes158, evaluation results from the earliest Sure Start programmes159 suggest that centres need to approach the provision of evidence-based support very rigorously to drive measureable improvements in outcomes. This is reinforced by experiences of implementing evidence-based programmes which shows that rigour in implementation (and in particular ensuring‘fidelity’ to the proven model) is essential to be confident in delivering results.

Full implementation of the Healthy Child Programme

13. The Government’s programme on health visiting forms one aspect of its wider

commitment to improve the effectiveness and experience of services accessed by parents and families in the foundation years. While it is clear that health visitors are key to betterhealth in the foundation years, their unique skills in assessing health needs at a population level, at a community level, and at individual child and family level, make them central players in ensuring children develop well and parents and families live well.

14. The White Paper ‘Healthy Lives, Healthy People: Our strategy for public health in

England’, sets out a bold vision for a reformed public health system in England. TheGovernment is committed to growing, by 2015, the health visitor workforce by 4,200 and developing health visiting services to drive up health outcomes and reduce inequalities. So, as capacity in the workforce grows, we should see health visitors leading and contributing to:

o greater reach and influence in the wider community, promoting healthy lifestyles and social cohesion;

o improved planning of local services to reduce health inequalities;o reduction in the variation in quality of service provision and coverage of the

Healthy Child Programme and families reporting a high level of satisfaction with health visiting service provided;

o families feeling supported and able to make positive changes to their health and wellbeing;


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o children and families being offered preventive services tailored to their needs and all families can access evidence-based programmes;

o improved maternal mental health and well-being and increased uptake of immunisations and breast-feeding;

o early identification of need and appropriate response to meet need and earlyintervention safeguarding arrangements.

15. However, as the government targets for recruitment of 4,200 new health visitors are stillunderway, we have not yet seen a full implementation of the HCP programme. The HCPmust be implemented fully in order to respond to those families where children are not being adequately supported /protected on a pathway to secure attachment by ensuring:

o HV and midwives are resourced and trained fully160. o Adoption of a robust multi-disciplinary and integrated working approach. As

Frank Field161, Dame Tickell and Lord Laming162 advised ‘more needs to be done

to ensure that services are as effective as possible at working together to achievepositive outcomes for children’.

Making better use of social and emotional assessment

16. Effective assessment is a key tool for professionals to help them work out what support children and families need. This section of the report reviews age and frequency of social and emotional assessments (including assessment of emotional regulation) and trainingimplications. The suggestions made here are intended to inform further reviews or on-going evaluation of the Healthy Child Programme (HCP) or NICE guidelines.

17. Existing guidelines already provide a solid, evidence-based platform of guidance and have been well received by the sector. The HCP includes a suite of guidance forpractitioners on things to consider during reviews, screening, obesity, immunisation, injury prevention, speech communication and language, and social and emotional development. It has recently been supplemented by Preparation for Birth and Beyond and PRE-view163.

18. The Health Visitor Implementation Plan 2011-15164 sets out different levels of servicefrom Universal Services, through Universal Plus (offering a rapid response in particularinstances of need such as postnatal depression, sleeping problems, weaning or anyparental concerns) to Universal Partnership Plus which offers on-going support from the health visitor team in partnership with other local services for more complex cases.

Current assessment practice

19. We note that the Children and Young People’s Health Outcomes Forum has

recommended a new Public Health outcomes indicator measuring the proportion of mothers with mental health problems, including postnatal depression. We endorse this recommendation and suggest that this information could be routinely gathered through the Healthy Child Programme.

20. The table below compares the current HCP guidelines for screening for postnatal depression alongside the reality of current practice:


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HCP states: Current common practice Comments1. A full health and socialcare assessment of needs, risk and choices by 12 weeks of pregnancy. Notification to HCP teamof parents requiring additional early intervention andprevention

There is a massive amount to be included in this midwiferyassessment and even if more time could be made for mental health promotion issues this would be heavily diluted amongst all the form filling and information giving.

There is a need to separate outthis element for follow-up when women/families may be vulnerable. This would reflectthe HCP ‘progressive’

requirements.

Particularly important is the sharing of information with the rest of the HCP team when women are vulnerable e.g. due to troubled relationships ormental illness – this should be managed within current services by audit and training – it shouldn’t require extra resource,

just extra emphasis2. Preparation forparenthood classes toinclude: relationship issues and new roles and responsibilities; the parent-infantrelationship; emotionaland practical preparation for fatherhood

There has been disinvestment inparentcraft classes so they have often focused on the birth ratherthan these issues. There is a new impetus to improve the content ofcurrent classes with the publication of Pregnancy, Birth and Beyond (DH, 2012) and with sessions being run in conjunction with children’s centres. The realchallenge comes from the fact thatmany of the most vulnerable don’t

have the personal confidence to attend parentcraft classes so maybe the least likely to receive this input through that channel.

However, the health visitorantenatal contact at home is nowbeing prioritised and there will be increased coverage as HV numbers come up. Health visitors are bestplaced to cover these issues and also make an assessment ofvulnerabilities with the more vulnerable families through this contact. They can provide earlyinterventions and anticipatoryguidance to the mother and fatherif present.

We can expect these services to improve markedly over the next18 months.

After 28 weeks:Focus on emotionalpreparation for birth, care-infant relationship, care of the baby, parenting and attachment,

See above


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using techniques such as promotional interviewing:o Identify those in need

of further supportduring the postnatalperiod

o Establish whatsupport needs are

Birth to one week:Comprehensive newborn assessment within 72 hours by doctor or trained midwife – this focuses on physical issues

Promoting sensitiveparenting:o Introduce parents to

the ‘social baby’ by

providing them with information about the sensory andperceptualcapabilities of their baby using a range ofmedia or validatedtools (e.g. Brazeltonor NCAST)

The midwife is involved here - it would seem according to the comment by a professor ofmidwifery below, who has also been involved in NICE guidance production, and has a good understanding of practice that it is unlikely that there is more than patchy delivery of this importantrequirement

A big issue is the priority given to different parts of their role bymidwives. Clearly, the safety ofthe mother and baby at deliveryis an absolute priority.

Where midwives are trained inNBAS, or the NeonatalBehavioural Observation theyare almost certainly more likelyto use it but this is not universaltraining.

There may be a gap in relation to the general understanding in midwifery of the emotionalissues for infants as theirprofessional focus is more on the mother

1-6 weeksBy 14 days face to facereview with mother and father by health professional to include:

Introduce parents to the ‘social baby’ by providing

them with information about the sensory and perceptual capabilities oftheir baby using a range of media or validated tools (e.g. Brazelton or NCAST)

Assessment of maternalmental health (HCP and NICE)

These are the assessments mostlikely to have universal coverage by the health visitor service now. However, as with the midwife booking visit, there is a massive amount to fit in and currently this may be the only time some mothers see a health visitor in theirhome. It would be hard to introduce a video camera if the health visitor is only justestablishing a relationship of trustwith the mother.

Health visitors should include an emotional assessment of the parents in her assessment, but mosthaven’t been trained to also assess

the attachment relationship.

There is the opportunity forfollow-up assessment of parent-infant interaction by the health visitor in the clinic (attachmentbehaviour doesn’t develop until

11-12 months)

With training health visitors could observe parent-infant interaction at

The increase in health visitor numbers should allow for the emotional elements of the HCP and the recommendations in this reportto be fully implemented if notwith the first cohort of new health visitors then after thesecond but the process could start immediately with respect to training and prioritising.


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this visit and then follow up those clients where this seems poor asthis is within their universal plus guidelines

6 weeks to 6 months

Assessment of maternalmental health at 6-8 weeks and 3-4 months (HCP and NICE)

Health visitors see this assessmentas being a priority and try to fit itin now; some provide goodservices. NICE is reviewing the perinatal mental health guidance and will almost certainly reiterate its importance as the research base is ever strengthening for the earlydetection of depression.

To introduce a video assessmenthere would be enthusiasticallysupported by the profession, though its value needs clearexplanation to commissioners.

This could be introduced through a pilot in well-resourcedservices and preparing trainingthat could be disseminated more widely to future cohorts ofstudents and other areas.

The Institute of Health Visitingwould be very keen to supportthis process.

21. In addition to the HCP guidelines outlined in the table above, we note that plans are also in place to introduce an integrated health and early education review between age 2 and 2½ years. This builds on the Tickell recommendations and will help ensure earlyidentification of any development delay, or additional needs a child might have, and willinform support from providers, parents and other practitioners, to address those needs.

22. We note that the Children and Young People’s Health Outcomes Forum has

recommended a new Public Health outcomes indicator measuring the proportion of mothers with mental health problems, including postnatal depression. We endorse this recommendation and suggest that this information could be routinely gathered through the Healthy Child Programme.

23. Over time, as health visitor capacity increases, the coverage and quality of the HCPreviews in the foundation years should be able to increase. The HCP will offer a world-class service if fully implemented.

24. There is a significant task in explaining to commissioners the importance of investing in these interventions. Local Commissioning Boards and Health and Wellbeing Boards maywish to use the resources set out in the commissioning framework.

Recommendations on frequency and timing of social and emotional assessments

25. The 0-2 Special Interest Group proposed that timing and frequency of assessments shouldclosely follow the current NICE guidelines with two variations:


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o Universal assessment at 3-4 months to assess the quality of the parent/infant interaction

and identify need for additional support to promote parental sensitive responsiveness.

o Proposed additional assessment as part of targeted offer at 12-15 months to assess

the infant’s attachment behaviour. At this age the infant will have developed clear attachment

behaviours as well as strategies to regulate emotionally, or not. This age therefore offers the first

opportunity to assess for risk and resilience in the infant and is also early enough for targeted or

indicated interventions to help change a possible pathway towards insecure attachment and/or

pathology. The assessment should be offered only to parents in the Universal Plus or Universal

Partnership Programme. Once the proposed assessment method is established in England, it is

proposed this additional assessment opportunity is added to the HCP at 12-15 months.

o Review moving the 2/2.5 year assessment forward to 22-24 months. As additional

support is soon to become available to vulnerable children at age 2, it is logical to move the 2.5

years review to an earlier time. Any significant emotional and/or social problems for the baby will

now be apparent and should emerge in a review/discussion between parents and practitioners.

These would be such issues as sleep problems, eating problems or general behaviour problems

and the practitioner can choose to rely on his or her professional judgements as to the severity of

these problems or choose to use a more formal assessment. Of particular importance at this time is

the assessment of early language development.

Social and emotional assessment methods and tools

1. Appendix 2 discusses a range of possible assessments and evaluation tools and their use.

Some are for universal application, others only in the assessment of vulnerable or

complex cases. Across the time period from early pregnancy to age two these assessments

are complementary, each adding information to the whole picture of offering the right

level of help and support at the right level of need 165,166 ,167,168

.

2. Some examples of possible assessment tools would be selective use of the Brazelton

Neonatal Behavioural Assessment (NBAS) or Neonatal Behavioural Observation (NBO)

scales during the first month of the baby’s life. This establishes the baby’s sensitivity to

external stimulation and helps the parents to understand the baby’s signals and cues. At 3-

4 months, when the parent-infant interaction will have developed its own rhythm and

patterns, an evaluation of the quality of the parent-infant interaction in terms of parental

sensitive responsiveness is crucial. This can be done using tools like the Parent-Infant

Interaction Observation Scale169

, The Keys to Interactive Parenting, the CARE Index or

similar. An additional dimension for assessment to establish risk is provided by

assessments of parental perceptions or attributions. This latter assessment could be done

by something like the Ages and Stages Questionnaire (ASQ), the Maternal Attitude

Scale170

or the Mother’s Object Relations Scale (MORS)171

. The 3-4 month assessment

would be universal.

Supporting the workforce

3. Families in the Foundation Years clearly positions a well-qualified and properly skilled

workforce as a key factor in making a real difference to the quality of support that

expectant parents and families with young children receive.


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Health professionals

29. The Government is acting to strengthen the Healthy Child Programme through its commitment to increase the health visitor workforce by 50 per cent. This expansion is intended to provide the capacity to lead comprehensive delivery of the Healthy Child Programme, through the health-visiting model set out in the Health VisitorImplementation Programme172. In addition, the Government is doubling coverage of theFamily Nurse Partnership over the same period.

30. As health professionals, all health visitors need to be competent and feel confident in order to assess effectively risk and resilience. Being able to analyse and understand parent-infant interaction is one of the most important skills a health visitor should have. At a universal level valid interactional assessment procedures are very valuable and could usefully be promoted as part of the HV transformational training programme. Health visitors should also be trained to administer appropriate tools for more vulnerable families as per the progressive universalism health visitor offer.

31. Effective training in assessment and understanding why certain tools might be moreappropriate for certain situations is crucial. Using an assessment tool insensitively can produce negative outcomes173. Studies of screening for dyslexia174,175 suggest that unless highly valid and reliable screening tools are available, it is better to rely on health visitors'and other practitioners' professional judgement to determine which young children do not appear to be developing in similar ways to their peers – which should trigger curiosityabout what the differences are, and what the reasons might be. Initial consideration ofthose questions will help practitioners determine which more targeted or specialistservices they should involve in undertaking more detailed assessments of the child and his/her family circumstances.

32. The skill of rapidly establishing and maintaining a trustworthy relationship is absolutelycentral to effective assessment as well as intervention. Approaches to support this include:

o For community midwives: training in the Family Partnership Model, supported byaccess to good clinical consultation opportunities from an antenatal, perinatal and infant mental health team176.

o For health visitors: training in the Motivational Interviewing Model, again supported by good clinical supervision from their local antenatal, perinatal and infant mental health team.

33. Effective training in the use of specific approaches includes:

o For midwives: training in the administration and scoring of the Hospital Anxietyand Depression Scale, as well as being able to enquire sensitively about risk and resilience aspects of the family.

o For community midwives: training to undertake the Newborn Behavioural Observation.

Early years’ professionals

34. Families in the Foundation Years demonstrated that high-quality pre-school programmes can significantly improve outcomes, especially for disadvantaged children, boys and


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children with special educational needs177. Evidence in the Families in the Foundation pack demonstrated that early education has the biggest impact when it is high-quality, and that the quality of the workforce is the most important factor178.

35. The existing and revised standards for Early Years Professional Status (EYPS) are strongon child development and in particular on social and emotional development, communication and relationships. To achieve EYPS, practitioners now have to demonstrate practice and leadership of practice with children across the birth-to-5 agerange. Many practitioners and training providers have a strong focus on practice with babies.

36. However, there has been a tradition and culture of having the least experienced and least well-qualified staff with some of the youngest children. There are some signs that this is changing and employers and practitioners need to continue to address this, and this is an issue that has been raised in the Nutbrown review.

37. For the youngest children, there are some specific needs, and the childcare sector needs to prioritise these. There is a rapid growth currently in the number of under-2s attendingnurseries /early years' settings, and as the government implements its commitments to offer free early education for the most disadvantaged 2-year-olds, the number of veryyoung children in these settings will increase rapidly. Ofsted have agreed to include in their revised inspection framework a greater focus on quality of settings for under-2s, but there is a great deal that providers and professionals can do to support the very youngest children more effectively.

38. The ‘common core’ set out by the Children’s Workforce Development Council describes the skills and knowledge that everyone who works with children and young people (including volunteers) is expected to have in order to work most effectively. It was revised in 2010.

39. In the context of working with 0-2 year-olds the group felt that there are three common

core knowledge areas of focus:

o core knowledge that informs all interactions with infants and toddlers, o core knowledge of child development from pre-birth to three years, and o an effective working knowledge of the interface with safeguarding systems.

40. In the context of working with 0-2 year-olds, three core skill areas were highlighted as particularly important in order to build an emotionally intelligent workforce:

o core skills around interactions with infants and toddlers, o skills to intervene in child development and o skills to form empathetic relationships with parents in a professional capacity.

41. Appendix 3 contains these core knowledge and skills sets and describes how this coreknowledge might look when employed by a member of the workforce engaged with 0-2 year-olds and their families. It is recommended that the revised National Professional Qualification in Integrated Centre Leadership takes account of these.

42. Within this framework, our work suggests the following 4 important priorities for thoseworking in childcare settings with 0-2 year-olds:


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1. Understand attachmentIt is generally accepted that infants can and do form secure attachments with a small numberof key caregivers, including early years’ practitioners. Attachment is an important feature of good early years practice in a number of respects:

o practitioners should have a good understanding of attachment as it relates to the child’s

key relationships and their own relationship with the childo practitioners should be able to build warm, responsive and sustained relationships with

young children confirmed by visual, auditory and physical contacto continuity and consistency of primary care is important e.g. key person systems. The

revised EYFS statutory framework for the early years’ foundation stage requires providers to assign a key person to every child to ensure that every child’s care is tailored

to meet their own individual needs, to help the child become familiar with the setting, offer a settled relationship for the child and build a relationship with their parents.

2. Support effective parentingIt is critical that the workforce has the skills to offer evidence-based interventions, includingparenting programmes, where appropriate.

3. Understand the importance of speech and language developmentIt is recognised that Personal, Social, and Emotional Development, Communication and Language, and Physical Development are prime areas of learning for our youngest children. Recent research has shown that language development at age two is very strongly associated with later school readiness, with the early communication environment in the home providingthe strongest influence on language at age two – stronger than social background179. High-quality support for speech, language and communication skills is essential for both effectiveparenting and good early years’ provision. Much has been achieved around earlycommunication and language with the ECaT programme180, but more needs to be done to secure the next stage of the programme – Early Language Development Programme – across the country.

4. Develop practitioners and managers who are emotionally competentEmpirical evidence exists on the research evidence on the fundamental importance of emotional intelligence (or competence) of the Early Years’ sector workforce

181,182.Guidance documentation produced as part of the selection process for health visitors outlines some of the personal and professional attributes that have been agreed as important to the successful delivery of the health visitor role. The guidance document (Appendix 3) demonstrates how, for health visitors, it has been possible to specify the personal as well as the professional attributes required for entry into training for the profession. This approach is helpful to see how it might be possible to select would-be early years’ staff for theiremotional resilience and emotional intelligence.


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Keeping up to date with the evidence

43. The research and understanding of best practice focused on working with under-2s –particularly in the childcare sector – is evolving rapidly. There is a huge amount of evidence for practitioners to digest, and in order to disseminate key messages to inform practice, there is a case for regular updates to keep busy professionals well informed.

44. The publication of the revised EYFS and a re-modelled Development Matters in spring2012 provides an excellent opportunity to refocus on the needs of under-2s. To support the Families in the Foundation Years, 4children is collating best practice examples of working with under-2s, highlights of research, and making available ‘Birth to ThreeMatters’

183, in response to the voice of the sector.

Supervision

45. Whatever their specialism, practitioners in the foundation years have a common commitment to children’s healthy growth and development and working with theirfamilies. Families in the Foundation Years outlined that in order to make this goal a reality there needed to be motivated, qualified, and confident leaders and professionals across health, early years and social care committed to working closely together in theinterests of children and families.

46. In order to be most effective in the context of working with the 0-2s, the workforce needs not only to be highly skilled, but should also receive regular, effective supervision, and possibly access to specialised consultations. Effective supervision is one of the keys to delivering positive outcomes for everyone. It is important for all organisations to have an unambiguous commitment to a well-structured supervision system, provided in thecontext of a clear organisation approach/culture.

47. Professional reflective supervision provides the opportunity for facilitated in-depth reflection on issues affecting practice. It is a process whereby the supervisor can clarifythe dynamics that operate between the family and the supervisee and can ensure that safepractice is maintained for both the family and the practitioner. Supervision includes discussion and problem solving for both administrative and clinical tasks.

48. The process includes devoted time to explore the thoughts and reactions of thepractitioner to the intensity and specific focus of the work and provides the opportunityfor both supervisor and supervisee to reflect on the practitioner’s work with infants, their parents, wider families and their joint work with other professional practitioners within the network.


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Intervening early and the economic case for thisapproach

In this chapter, we:

o acknowledge the important contributions of the recent reviews in the early years;o review the importance of holistic understanding and approaches to early years’

intervention;o review the economics of early years’ investment and the implications for the UK.

Holistic and integrated approach to early years’ intervention

1. Supporting Families in the Foundation Years states the case for early years’ intervention

is clear. Reviews conducted by Professor Sir Michael Marmot184, The Rt Hon Frank Field MP185, Graham Allen MP186, Dame Clare Tickell187 and Professor Eileen Munro188 haveall reinforced the importance of early intervention in the foundation years. SupportingFamilies also outlined how the Government is encouraging early intervention in thefoundation years by:

o helping professionals use their interactions with families as opportunities to identifyadditional needs and offer further help;

o introducing an integrated child development review at around age two to two-and-a-half;

o supporting professionals with their role in early help as part of the new arrangements following the Munro review of child protection;

o encouraging evidence-based parenting programmes, and doubling the number offamilies benefiting from the Family Nurse Partnership; and,

o setting out a new core purpose for Sure Start Children’s Centres, with earlyintervention at its heart.

2. Policy thinking on early intervention has developed at a pace recently thanks to thepositive contributions of Tickell, Allen, Field and Munro. These independent reviews alldemonstrate the benefit of a holistic understanding of early years’ intervention. As such,

there is no single service which provides the ‘frontline’ of early years’ intervention:

children’s centres, maternity services, health services including health visitors, GPs and

A&E, schools, colleges, nurseries and childminders, are all well placed to recognise when a child or their family may need extra support or for a professional to step in quickly to protect a child.

3. Evidence-based and well-implemented preventive services and early intervention in thefoundation years are likely to do more to reduce abuse and neglect than reactive services and (in the long run) deliver economic and social benefits. Prevention and early years’

intervention are likely to be more cost-effective if very well targeted – the cost per child is lower but you need to ‘treat’ more children because you don’t know which ones will

need the intervention. Such services also have an important role in making sure allchildren reach school ready to learn and can achieve to the best of their abilities.


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4. Chapter 1 concludes that multiple needs are linked to the biggest problems in youngchild development. It is important that services have a shared local understanding of how early years’ intervention operates in practice locally. In both universal and targeted services, effective multi-agency working and coordination are needed so that each member of the workforce understands their role and takes responsibility to help identifyissues and either refer or provide help. There continues to be a key role for Sure Start Children’s Centres in this integrated working process.

The economics of early years’ investment

5. As part of the work of the Special Interest Group, a review was conducted of a wide rangeof published UK and international studies that examined the economic case forinvestment in the early years. The approaches used by the researchers were diverse. Theyincluded 7 UK and 15 non-UK cost-benefit analyses, 14 non-UK assessments of internal rate of return, 10 UK social return on investment studies, together with a series of alternative approaches including breakeven analysis, odds ratios, case studies and econometrics. (See Appendix 4 for detail.)

6. The majority of the Randomised Control Trials that measured the impact of early years’

programmes (and cost-benefit analyses based on them) were of American origin189,190,191. The consensus among these American approaches and reviews, including even the mostcautious and circumspect in its recommendations, suggested returns on investment on well-designed early years’ interventions significantly exceed both their costs and stock

market returns. The rates of return ranged between $1.26 and $17.00 for every $1 invested in the RAND studies; between $4.05 and $17.92 for every $1 invested in theReynolds Chicago studies; and between $1.75 and $10.32 for the Washington StateInstitute for Public Policy studies. All the researchers found a small minority of earlyyears’ programmes which did not deliver a return, either because of poor design, or because an experimental intervention did not prove as successful as had been hoped.

7. The studies conducted in the UK lack the breadth and rigour of the American evaluations. Nonetheless, a similar pattern of results was found. Cost-benefit192,193,194, predictive 195,196,197 and case study198,199 approaches showed clear indications of economic payback. The nine Social Return on Investment studies200,201,202 showed returns of between £1.37 and £9.20 for every £1 invested (with an average return of £3.65). Two cost-benefit studies (Croydon Total Place203 and an LSE study of parenting programmes for conduct disorder204) predicted and produced returns of £10 and £8 per £1 invested respectively.

8. There have been two UK RCTs which assessed the economic benefit of early years’

interventions. Both applied relatively weak interventions to very challengingcircumstances, and their results were mixed.

9. The Social Support and Family Health Study205 provided a home visit listening service of almost 40 minutes per month to new mothers in deprived districts of Camden and Islington. The study was cost neutral, its small outcome benefits (in terms of reduced costs to health services) being annulled by the costs of training and delivery. This came as no surprise to the service providers, given the serious and complex nature of the challengeand relatively low level of support provided, which the providers did not believe adequate to counteract the effects of social and material disadvantage. One outcome was improved


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(workplace) productivity for the recipients which could, over time, make a longer-term positive economic impact on society.

10. The other UK RCT, the Oxfordshire Home Visiting Study206, was inconclusive as to financial benefits. This was a brave study which did not select the more responsive first-time mothers which FNP recommends; it worked only with mothers who had five or moreserious risk factors such as domestic violence, alcoholism or mental health problems; the mothers were supported for one year less than with FNP (18 rather than 30 months); and its training component was very light compared with FNP.

11. There were indications that the Oxfordshire trial did reduce child abuse and harm (possibly by identifying ‘at risk’ infants early). If so, it probably produced worthwhileeconomic returns (see Appendix 4). In this trial there were two suspicious child deaths within the control group and none in the trial group, which put more children on the Child Protection Register. It also produced a number of other subsidiary benefits.

12. The consensus among the American approaches and reviews, including even the mostcautious and circumspect in its recommendations, suggested returns on investment on well-designed early years’ interventions significantly exceed their costs.

13. Across the approaches examined there was a range of benefits, with rates of return on investment significantly and repeatedly proposed to be higher than those obtained from most public and private investments207.

14. One approach to determining the value of investment in the early years is based on econometrics. Heckman208 in his economic analysis of the early years, argues that structures (including knowledge and skills) are based on foundations and the stronger thefoundations the more solid the structure. Heckman argues that financial returns on earlyyears’ investments are highest for age 0-3, and diminish progressively as children become older, and concludes that currently society is demonstrably under-investing in the earlyyears.

15. Heckman also points out particular characteristics of early years’ investment, not found with investments in later years. Cunha and Heckman209 point out that because early years’

interventions both promote economic efficiency and reduce lifetime inequality, theyprovide policy makers with a rare ability to spend money in a way which delivers both social and economic benefits at the same time.

16. The countries of Scandinavia have consistently led international comparisons in terms of welfare210. Recognising the value of prevention and early intervention programmes, in thelast 20-30 years these countries have increased this type of investment211. Sweden and Norway provide examples of where whole countries have adopted a policy of investment in early years’ prevention and received not only financial returns but better health for the

whole population. The benefits span lower infant mortality at birth through to reduced heart, liver and lung disease in middle-age212.

17. The Scandinavian results reflect the effects of a range of factors including a well-resourced and professional healthcare service with a strong focus on prevention, and widespread recognition of the value of focusing resources at the very beginning of life.


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18. The logical links between the investments and benefits are described in the AdverseChildhood Experiences’ (ACE) studies

213 which suggest that for every 100 cases of child abuse society can expect to pay in middle or old age for:

o one additional case of liver diseaseo two additional cases of lung diseaseo six additional cases of serious heart disease, and o 16% higher rate of anti-depressant prescriptions

None of these estimates takes account of the economic value of the inter-generational effects of breaking the cycle of disadvantage. Child abuse averted in one generation will itself resultin a cumulative reduction in this dysfunction during future generations.

Implications for the UK

19. Although the international evidence is powerful and compelling, and has alreadyinfluenced the Scottish Parliament214, it cannot necessarily be translated to the UKdirectly. Unlike the United States, we are fortunate to have universal health provision and in particular the DH Healthy Child Programme (HCP), which aims to focus on theprovision of a universal preventive service, providing families with a programme of screening, immunisation, health and development reviews, supplemented by advicearound health, wellbeing and parenting. In addition, we have extensive publicly-provided early education, including in England the new commitment to provide early education for all disadvantaged 2-year-olds.

20. Nevertheless, there are substantial gaps in early intervention services. A recent review of local Health Boards found very patchy implementation of the Healthy Child Programme, with many areas not even knowing whether it was being implemented or not. There is aclear, demonstrable need to provide the right kind of support earlier to prevent and tackle child neglect and a range of risk factors more effectively. The economic case for this in the UK has been clearly set out in the Allen and Field Reviews and is borne out by the good economic returns from the significant majority of the UK studies.

21. Besides many studies illustrating the powerful case in principle to emphasise earlyinvestment in support for children, it is very clear that we are not getting early years’

intervention right – as illustrated by numerous cases of child maltreatment, wide gaps in school outcomes, poor scores in international comparisons of child wellbeing, high youth crime and poor health outcomes. There remains a strong case for improving our investment in priority areas.

22. The Family Nurse Partnership (FNP) is a good example of an intensive support programme with proven long-term impacts, that is available to parents in some areas to help them overcome these difficulties and promote the well-being of their children. TheFNP offers intensive, targeted support for the most vulnerable first-time young mothers. It is a licensed, preventive programme offering intensive and structured home visiting, delivered by specially trained nurses, from early pregnancy until the child is aged two. The nurses use practical activities and strength based methods that change behaviour and tackle the emotional problems that prevent some mothers and fathers caring well for theirchild.


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23. Family nurses deliver the Healthy Child Programme for their clients, and share common goals with health visiting, but FNP works in a different way, including work at a deeper level on the emotional problems and behaviours that prevent some parents from givingtheir child the best start in life. The Group welcomes plans to double the number of places on the Family Nurse Partnership (FNP) programme, to at least 13,000 by 2015.

The Big Lottery project – Fulfilling Lives: A Better Start

24. The Under 2s Special Interest Group (SIG) work has already contributed to a significant development in the goal of improving the lives of the country’s children. The Big Lottery

Fund (BIG) is to invest £165m in prevention-focused early years’ intervention projects in

up to five local areas in England, over a period of up to ten years, as part of their A Better Start initiative.

25. This money will support systemic approaches to improve outcomes for children from pre-birth to age 3, through primary prevention, in areas of 50,000 population with high levels of disadvantage. £30-£50m will be allocated to consortia led by voluntary sector organisations in 3-5 local authority areas. The chosen areas will be announced in March 2014, following a development stage in 2013, during which BIG will support 10-15 local areas to create sustainable plans to bid for the cash.

26. During the design and set-up of this project the main Under 2s SIG recommendations were presented to and discussed in depth with the Big Lottery Fund, and played asignificant part in the outline shape of the core part of the project which is intended to promote babies’ and children’s social and emotional development, language development

and nutrition.

Need for better UK evaluation

27. Historically there has been a dearth of really strong evaluation evidence for early years’

interventions in the UK, making it difficult for commissioners to understand which approaches are most cost-effective for them. As can be seen from Appendix 4, this shortfall is being bridged. However, it remains an imperative to become much better at properly evaluating programmes and to be clear which programmes or approaches offer the greatest improvement in outcomes and the best returns in a UK context. Monitoringdata from Local Areas where investment is being reprioritised might be helpful, such as the Children’s Improvement Board learning from the 18 development demonstrator sites,

the evaluations of the Big Lottery and any future early years’ evaluations by the Early

Intervention Foundation.

28. A ma orward will come with the £165m B Lotter Fund A Better Startinitiative, which has set aside a nificant sum for evaluation of the success of the 3-5 selected local areas, both in i outcomes for babies and children and in terms oftheir cost-benefit performance.

29. The previous chapter considers how we can make best use of universal services, includingnew investment in health visitors and early years’ workforce, to improve outcomes in

pregnancy and for our youngest children. The framework for commissioners (see page50) also identifies a range of resources to help commissioners identify specificprogrammes and approaches to assessment and support which they can use to improveearly intervention services.


42

References

Recommendations1

Reflective Video Feedback is the general approach whilst Video Interactive Guidance is a particular “school”.

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83 Jacobsen, T. Edelstein,W. Hofmann, V. (1994). A longitudinal study of the relation between representations of attachment in childhood and cognitive functioning in childhood and adolescence. Developmental Psychology. 30, 112-12484 Radke-Yarrow, M. (1991). Attachment patterns in children of depressed mothers. In Parkes, C. Stephenson-Hinde, J. Marris, P. (Eds) Attachment across the lifecycle, London: Routledge, 115-12685 Ghate, D. Hazel, N. (2002). Parenting in poor environments: stress, support and coping. London: JessicaKingsley Publishers.There are also other estimates that the proportion might be higher – see for example reference 88.86 HM Treasury. Department for Education and Skills (2007) Policy Review of Children and Young People: A Discussion Paper. London: Department for Education and Skills. 87 Meltzer, H. Gatward, R. Corbin, T. Goodman, R. Ford, T. (2003). The mental health of young people lookedafter by local authorities in England: summary report, London: The Office for National Statistics88 Carlson, V. Cicchetti, D. Barnett, D. Braunwald, K. (1989). Disorganized/disoriented attachment relationships inmaltreated infants. Developmental Psychology, 25, 525-531.89 Barlow, J. Svanberg P.O. (2009). Keeping the Baby in Mind: Infant Mental Health in Practice. London: Routledge90 Landy, S. (2000). Assessing the risks and strengths of infants and families in community-based programs. In Osofsky, J. D. Fitzgerald, H. E. (Eds) WAIMH Handbook of Infant Mental Health. Vol. 2: Early Intervention, Evaluation, and Assessment. New York: John Wiley & Sons, 335-37591 Ghate, D. Hazel, N. (2002). Parenting in poor environments: stress, support and coping. London: JessicaKingsley Publishers92

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143 Kunzke, D. Strauss, B. et al. (2002). The significance of traumatic experiences and attachment disturbancesfor the onset and psychotherapy of alcoholism: A literature review. Zeitschrift fuer Klinische Psychologie, Psychiatrie und Psychotherapie, 50(2), 173-194.144 Liotti, G. Pasquini, P. (2000). Predictive factors for borderline personality disorder: patients' early traumaticexperiences and losses suffered by the attachment figure. Acta Psychiatrica Scandinavica 102(4), 282-289145 Felitti, V.J. Anda, R.F. Nordenburg, D. Williamson, D.F. Spitz, A.M. Edwards, V. Koss, M.P. Marks, J.S.(1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death inadults. American Journal of Preventive Medicine. 14 (4), 245-58146Enlow, M.B. Egeland, B. Blood, E.A. Wright, R.O. Wright, R.J. (2012). Interpersonal trauma exposure andcognitive development in children to age 8 years: a longitudinal study. Journal of Epidemiology and CommunityHealth. DOI: 10.1136/jech-2011-200727147 Marmot, M. (2010). Fair Society, Healthy Lives, Strategic Review of Health Inequalities in England post 2010. Department of Health

Supporting chapter 2: Making best use of resources for 0-2s148 Department for Education. (2010). Working Together to Safeguard Children: A guide to inter-agency workingto safeguard and promote the welfare of children, London: Department for Education149 op cit150 Department of Education. (2012). Core purpose of Sure Start Children’s Centres [Online] Available at:http://www.education.gov.uk/childrenandyoungpeople/earlylearningandchildcare/a00191780/core-purpose-of-sure-start-childrens-centres [Accessed: 14th January 2013]151 Statham, J. Smith, M. (2010). Issues in Earlier Intervention: Identifying and supporting children with additionalneeds. Research Report 205. London: DCSF152Royal College of Midwives published Reaching Out: Involving Fathers in Maternity Care and Top Tips for Involving Fathers in Maternity Care (Nov 2011) to support maternity service staff with encouraging theinvolvement of fathers throughout pregnancy and childbirth, and into fatherhood and family life.Royal College of Midwives. (2011) Reaching Out: Involving Fathers in Maternity Care. [Online] Available at:http://www.rcm.org.uk/college/policy-practice/government-policy/fathers-guide/153 Leadership for Local Government (Date Unpublished). Thinking Family: a new approachfor tackling social breakdown: Westminster City Council’s Family Recovery Programme [Online]Available at: http://www.westminster.gov.uk/workspace/assets/publications/Thinking-Family-1256302181.pdf[Accessed: 14th January 2013]154 Cuthbert, C. Rayns, G. Stanley, K. (2011). All Babies Count. London: NSPCC155 Siraj-Blatchford, I. Siraj-Blatchford, J. (2010). Improving development outcomes for children though effectivepractice in integrating early years services. London: Centre for Excellence and Outcomes in Children and YoungPeople (C4EO)156 Matrix Evidence Ltd (2009) Valuing Health: developing a business case for health improvement. [Online]Available at: www.idea.gov.uk/idk/aio/15246941 [Accessed: 14th January 2013]157 Identified as part of the DH Task and finish group Report - Children’s centres and health visitors: unlocking thepotential to improve local services for families158 University of Oxford. (2009). Evaluation of Children’s Centres in England [Online] Available at:http://www.education.ox.ac.uk/research/fell/research/evaluation-of-children-centres-in-england-ecce/ [Accessed: 14th January 2013]159 Birkbeck University. (2012). BBK NESS Site [Online] Available at: http://www.ness.bbk.ac.uk/ [Accessed: 14th

January 2013]160 Four year transformational programme currently in operation of recruitment and retention, professionaldevelopment and improved commissioning linked to public health improvement.161 Field, F. (2010). The foundation years: preventing poor children becoming poor adults. London: TheStationery Office162 Laming, L. (2009). The protection of children in England: A progress Report. London: The Stationery Office.163 Chimat (2011) see http://www.chimat.org.uk/preview PRE-view is a predictive tool developed to help healthprofessionals target the Healthy Child Programme effectively in order to optimise child outcomes.Chimat. (2011). PRE-view planning resources. [Online] Available at: http://www.chimat.org.uk/preview [Accessed: 14th January 2013]164 Department of Health. (2011). Health visitor implementation plan 2011-15: a call to action, February 2011.London: Department of Health165 Baggett, K. M. Warlen, L. Hamilton, J. L. Roberts, J.L. Staker, M. (2007). Screening Infant Mental HealthIndicators; An Early Head Start Initiative. Infants & Young Children, 20 (4), 300-310.166 Carter, A.S. (2002). Assessing Social-Emotional and Behavior Problems and Competencies in Infancy andToddlerhood: Available Instruments and Directions for Application. In Zuckerman, B. Lieberman, A. Fox, N. (Eds)Emotional Regulation and Developmental Health: Infancy and Early Childhood., New York: Johnson & JohnsonPediatric Institute, 277-299.

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167 Denham, S.A. Wyatt, T.M. Bassett, H.H. Echeverria, D. Knox, S.S. (2009). Assessing social-emotionaldevelopment in children from a longitudinal perspective. Journal of Epidemiology and Community Health, 63,(Suppl 1), i37-i52.168 Ringwalt, S. (2008). Developmental screening and assessment instruments with an emphasis on social andemotional development for young children ages birth through five. Chapel Hill: The University of North Carolina, FPG Child Development Institute, National Early Childhood Technical Assistance Centre.169 Svanberg, P.O. Barlow, J. Tigbe, W. (in press); The Parent-Infant Interaction Observation Scale: Reliabilityand Validity of a screening tool. Journal of Reproductive and Infant Psychology.170

Bor, W. Brennan, P.A. Williams, G.M. Najman, J.M. O’Callaghan, M.: A mother’s attitude towards her infant and chlild behaviour five years later. Australian and New Zealand Journal of Psychiatry, 2003, 37: 748 -755171 Oates, J. Gervais, J. (XX) Mothers' models of their infants. Journal of Reproductive and Infant Psychology172 Department of Health. (2011). Health visitor implementation plan 2011-15: a call to action, February 2011. London: Department of Health173 Mitcheson, J. Cowley, S. (2003). Empowerment or control? An analysis of the extent to which client participation is enabled during health visitor/client interactions using a structured health needs assessment tool. International Journal of Nursing Studies 40, 413-426174 Simpson, J. Everatt, J. (2005). Reception class predictors of literacy skills. British Journal of EducationalPsychology, 75 (2) 171–188175 Guerin, D. Griffin, J. Gottfried, A. Christenson, G. (1993). Concurrent validity and screening efficiency of The

slexia Screener. Psychological Assessment, 5(3), 369-373Davis, H. (2009). The Family Partnership Model: Understanding the Processes of Prevention and Early

Intervention. In Barlow, J. Svanberg, P.O. (Eds) Keeping the baby in mind; Infant Mental Health in Practice,Hove: Routledge.177 Siraj-Blatchford, I. Mayo, A. Melhuish, E. Taggart, B. Sammons, P. Sylva, K. (2011). Performing against theodds: developmental trajectories of children in the EPPSE 3-16 study. Research Report DFE-RR128,Department for Education,178 N.B.This evidence pack underpins the Government's vision set out in the overall Families in the FoundationYears policy statement. Department for Education (2011). Families in the Foundation Years - Evidence Pack[Online] Available at: https://www.education.gov.uk/publications/standard/publicationDetail/Page1/DFE-00214-2011 [Accessed: 14th January 2013]179 Roulstone, S. Law, J. Rush, R. Clegg, J. Peters, T. (2011). The role of language in children’s early educationaloutcomes. Research Brief RB134 London: DfE, 180 Department for Education. (2011). Every Child a Talker (ECaT) [Online] Available at:http://webarchive.nationalarchives.gov.uk/20110809091832/http:/teachingandlearningresources.org.uk/early-years/every-child-talker-ecat [Accessed: 14th January 2013]181 Elfer, P. Grenier, J. Manning Morton, J. Dearnley, K. Wilson, D. (2008). The Key Person in Reception classesand small nursery settings, Social and Emotional Aspects of Development: Guidance for Practitioners working inthe Early Years Foundation Stage. London.182 Elfer, P. Dearnley, K. (2007). Nurseries and emotional well being: Evaluating an emotionally containing modelof continuing professional development, Early Years: An International Journal of Research and Development, 27(3), 267-279183 Department for Education. (2005). Archive – Birth to Three Matters [Online] Available at:https://www.education.gov.uk/publications/standard/publicationDetail/Page1/Birth [Accessed: 14th January 2013]

Supporting chapter 3: Intervening early and the economic case for this approach184 Marmot, M. (2010). Fair Society, Healthy Lives: Strategic Review of health inequalities in England post-2010, London: The Marmot Review.185 Field, F. (2010). The Foundation Years: preventing poor children becoming poor adults, London: TheStationery Office.186 Allen, G. (2011). Early Intervention: The Next Steps. London, Cabinet Office.187 Tickell, C. (2011). The Early Years: Foundations for life, health and learning, London: The Stationery Office.188 Munro, E. (2011). The Munro Review of Child Protection Part One: A systems analysis, London: TheStationery Office.189 Karoly, L.A. Kilburn, M. R. Cannon J.S. (2005). Early Childhood Interventions: Proven Results, FuturePromise, The PNC Financial Services Group, Inc.190 Reynolds, A.J. Temple, J.A. White, B.A.B. Ou, S-R. Robertson, D.L. (2011). Age 26 Cost–Benefit Analysis of the Child-Parent Center Early Education Program, Child Development 82 (1), 379–404.191 Reynolds, A.J. Temple, J.A. White, B.A.B. Ou, S-R. Robertson, D.L. (2011). Age 26 Cost–Benefit Analysis of the Child-Parent Center Early Education Program, Child Development 82 (1), 379–404.192 NICE (2006). Assessment Group evaluation of parent-training/education programmes in the management of children with conduct disorders, London: NICE.


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193 Morrell CJ, Warner R, Slade P, Dixon S, Walters S, Paley G, et al. (2009). Psychological interventions forpostnatal depression: cluster randomised trial and economic evaluation. The PoNDER trial. Health TechnolAssess,13(30)194 Knapp, M., McDaid, D. and Parsonage, M. (editors) (2011). Mental health promotion and mental illnessprevention: The economic case, London: Department of Health.195 Action for Children and New Economics Foundation (2009). Backing the Future: why investing in children isgood for us all, London: new economics foundation.196 Greater London Economics (2011). Early years interventions to address health inequalities in London – theeconomic case, London: Greater London Authority.197 Pillai, B. (2010). How could we reduce child maltreatment in the UK by 70%, and at what cost? unpublishedstudy, London: WAVE Trust.198 Jones, A. (unpublished case studies on North-East London Foundation Trust perinatal mental health service, provided to the Under 2s SIG study, 2012).199 Livesley, J., Long, T., Murphy, M., Fallon, D., Ravey, M. (2008). Evaluation of the Blackpool Budget-HoldingLeading Practitioner Project. Salford: University of Salford. 200 C4EO (2010) Grasping the nettle: early intervention for children, families and communities London: NationalChildren’s Bureau [Case studies on Blackpool breastfeeding project and I CAN Early Talk project in Kent]201 Action for Children and New Economics Foundation (2009) Backing the Future: why investing in children isgood for us all, London: new economics foundation. [Case studies on Wheatley Children’s Centre, Doncaster and

East Dunbartonshire Children’s Centre]202 Mason, P., Salisbury, D. & Mathers, I. (2012). The Value of Early Intervention: findings from Social Return onInvestment research with Barnardo’s children’s centres. Birmingham: ICF GHK. [Case studies on Stay and Play, Bournemouth; Family Support Workers, Warwickshire; Triple P: Brock House, Somerset; and Tiny Toes: Hazlemere and Loudwater Children’s Centres]203 NHS Croydon and Croydon Council (2010). Child: Family: Place: Radical efficiency to improve outcomes for young children. Croydon Council, Croydon204 Knapp, M., McDaid, D. and Parsonage, M. (editors) (2011) Mental health promotion and mental illnessprevention: The economic case, London: Department of Health.205 Wiggins, M., Oakley, A., Roberts, I., Turner, H., Rajan, L., Austerberry, H., Mujica, R. and Mugford, M. (2004). The Social Support and Family Health Study: a randomised controlled trial and economic evaluation of twoalternative forms of postnatal support for mothers living in disadvantaged inner-city areas. Health TechnolAssess, 8(32).206 Barlow, J., Davis, H., McIntosh, E., Kirkpatrick, S., Peters, R., Jarrett, P. & Stewart-Brown, S. (2008). TheOxfordshire Home Visiting Study: 3 Year Follow-up. Warwick: University of Warwick.207 Grunewald, R. Rolnick, A.J. (2003). Early Childhood Development: Economic Development with a High PublicReturn. The Region, 17(4), Supplement, 6-12.208 Heckman, J.J. (2008). Schools, Skills and Synapses, Economic Inquiry, 46(3): 289-324.209 Cunha, F. Heckman, J.J. (2007) The technology of skill formation. American Economic Review, 97(2), 31–47.210 Wilkinson, R. Pickett, K. (2009). The Spirit Level: Why More Equal Societies Almost Always Do Better, England: Allen Lane.211 Socialstyrelsen (1997). Stöd i föräldraskapet (Support in Parenting), Socialdepartementet Dept. for SocialWelfare, HM Government. 161.212 Killén, K. (2000). Barndommen varer i generasjoner (Childhood lasts for generations). Oslo, Kommuneforlaget. Sweden.213 Felitti, V. Anda, R. (2010). The Relationship of Adverse Childhood Experiences to Adult Health, Wellbeing,Social Function and Health Care. In Lanius, R. Vermetten, E. Pain, C. (Eds) The Effects of Early Life Trauma onHealth and Disease: The Hidden Epidemic. Cambridge: Cambridge University Press, Chapter 8214 Scottish Government. (2011). Scottish Spending Review 2011 and Draft Budget 2012-13. [Online] Available at :http://www.scotland.gov.uk/Resource/Doc/358356/0121130.pdf [Accessed 14th January 2013]


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Local commissioning for very early child development:

A framework

This framework draws on work from the Special Interest Group for children from conception to age 2. It aims to provide a framework for commissioners to help guide thinkingabout issues to consider with the aim of improving child development outcomes through better local support in very early childhood.

A – PREVENTION

A1 – Pregnancy

o Evidence shows that development begins before birth and that the health of a baby is crucially affected by maternal health and well-being. Low birth weight in particular is associated with poorer long-term health and educational outcomes.

o Effective measures to reduce risky behaviours such as smoking, drug and alcohol consumption during pregnancy can reduce levels of foetal alcohol syndrome, improvechild IQs and reduce levels of mental difficulty.

o Children born to mothers who experienced antenatal stress, anxiety or depression have more emotional difficulties, especially anxiety and depression, and symptoms of ADHD and conduct disorder than children born to non-stressed mothers. Thesechildren also perform at a lower cognitive level.

o Stress, anxiety and depression during pregnancy are frequently undetected and so nottreated. Research indicates that about 10-20% of pregnant women suffer antenatal depression and anxiety, and that levels at 32 weeks of pregnancy are greater than postnatally.

o Ante-natal depression (AND) and anxiety pose a significant risk for the baby through the direct action of chemicals on the brain of the foetus; and the fact that AND is a strong indicator for the later development of post-natal depression (PND).

o Targeting those exhibiting the ‘warning’ signs for PND in the ante-natal period has been shown to reduce the incidence/seriousness of depression following birth.

o Up to 20% of pregnant women experience mental and/or emotional illness requiringreferral for psychological therapies.

So in order to address issues of maternal mental health in pregnancy and promotestronger maternal self-efficacy it is helpful to consider the options below.

Specific options on Pregnancy

Ensure health professionals are well equipped to detect stress, anxiety and depression during pregnancy.

Provide referral to appropriate psychological or other interventions for antenatal anxiety and depression. Ensure there are enough trained professionals to provide thishelp.

Target maternal stress during pregnancy, for instance by focusing on reducingdomestic violence and supporting the quality of relationships during this stressful


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time. These measures could reduce the risk of children having symptoms of ADHD or conduct disorder and showing later criminal behaviour.

Consider whether ante-natal parent preparation classes could include a discussion on the emotional impact of becoming a parent and not just focus on the more practical elements of birth options and bathing a baby.

Resources

Chapter 1 page 10-12

From Chicago www.ounceofprevention.org gives examples of early intervention, includingthe highly successful Doula scheme that begins with the pregnant mother. www.nmha.org

The Department of Health new information service for parents https://www.nhs.uk/InformationServiceForParents/pages/home.aspx

For information on downloading a sign-up widget and adding it to your website email [email protected]

Maternity Commissioning Resource Pack to support Clinical Commissioning Groups is available at:http://www.commissioningboard.nhs.uk/files/2012/07/comm-maternity-services.pdf. By bringing together existing service specifications, benchmarking templates and otherresources, the Pack aims to make it easier for CCGs to have informed discussions with providers about service design and delivery and to focus on matters that will make the mostdifference to women and families.

A2 – Infant and parent mental health and assessment

A2.1 Secure attachment

o Secure children and adults are resilient, are able to regulate their emotions and experience empathy. Secure attachment relationships, although not a guarantee of future mental health, provide a protective factor, enabling children to develop ways to cope with such adversity as loss and trauma.

o Insecurely attached children are more vulnerable and they and their families need help. Without help, insecurely attached children begin to soak up statutory resources from an early age through such ‘externalising’ and ‘internalising’ behaviours as

aggression, non-compliance, negativity and immaturity, compulsive compliance and pervasive low self-esteem.

o Research indicates that overall some 35-40% of all parent-infant attachments areinsecure although this varies according to the stresses and vulnerabilities of the family.

The best time to introduce a universal assessment of the quality of interaction between mother and baby would at age 3-4 months. Earlier would of course be better but is not practical

https://www.nhs.uk/InformationServiceForParents/pages/home.aspx

mailto:[email protected]


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(without need for repeat visits) because of infant sleeping patterns. In order to promotesecure attachment and to assess better where attachment is insecure in babies arange of options can be considered:

Specific options – secure attachment

The following measures could be considered in relation to mother-baby interaction: Review health visitor training to include session on evaluation of the interaction

between the mother and baby (preferably via a short video clip). Ideally, this shouldbe carried out at a universal level and used as a determinant for the need for additional services such as Universal Plus.

In addition to the health visitor assessment carried out at age 6 weeks, add an assessment at 3-4 months, using the Parent Infant Interaction Observation Scale, TheKeys to Interactive Parenting Scale (KIPS)215, the CARE-Index216 or similar.

Introduce a reliable and valid assessment of attachment type at age 12 – 14 months. The gold standard of attachment assessment is The Strange Situation which unfortunately is too cumbersome and complex to be used in routine practice. An acceptable proxy measure is the TAS-45 measure, which could be adapted for routine use in England. Much of the necessary information can be collated and recorded via mobile devices such as tablets or laptops. A small investment would be required to ‘import’ the TAS-45 and develop the necessary training and data processing so it can be used in routine practice in England.

Promote interventions locally to develop secure attachment i.e. identifying parent-infant pairs who would benefit from support to improve attunement, followed byeither video interactive guidance or parent-infant psychotherapy (e.g. Video Interactive Guidance (University of Dundee); VIPP; Watch, Wait & Wonder, Circle of Security). Interaction Guidance has also been successfully used to improvesensitivity and decrease the amount of disrupted communication between mothers and babies with feeding problems217; and a slightly modified version has been shown to help mothers with postnatal depression re-connect with their babies218.

These need to be supported by the Perinatal Mental Health Support Systems referred to in section A2.2 (below) as parents are unlikely to provide secure attachment while still struggling with issues of mental health or their relationship with the child.

A2.2 – Specialist parent-infant psychotherapy support

o Early intervention can promote infant mental health and reduce the risk of children’s

development being hampered by abuse, neglect or other early parent-child relationship difficulties.

o Understanding of infant mental health is, at best, patchy outside the health sector, and few health professionals are trained in it.

o In the UK, 144,000 babies under one year of age live with a parent who has acommon mental health problem.

o Children of mothers with mental health issues are twice as likely to experience achildhood psychiatric disorder. If both parents have a mental health problem this


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doubles. And the disorder is likely to develop because of miscommunication within the attachment relationship even when the caregiving is otherwise fine.

o There is significant cross-over between mental health issues and alcohol/substanceabuse.

o If allocated earlier to preventive interventions and specialist perinatal therapeutic andpsychiatric services in the early years, investing early would reduce future drain on resources.

o Approximately 8% of pregnant women will subsequently be emotionally ill enough to warrant a referral to a specialist perinatal mental health service that focuses on restoring the mother’s mental and emotional health and the forming mother-babyrelationship – 55,200 mothers and at least 55,200 babies annually (Antenatal &Postnatal MH Commissioning Benchmarking Tool, March 2010). The needs of fathers will add to this figure.

o Based on recognised genuine referrals to the North East London NHS Foundation Trust (NELFT), the national figure for England may be around 75,000 cases of genuine need for perinatal psychotherapeutic support per annum. The potential benefits of robustly commissioning effective perinatal mental health services likeNELFT’s include:

Improving the mother-baby relationship and bonding with the aim of creatinga securely attached baby by 12 months and preventing the baby becoming achild at risk of emotional disturbance;

Reducing the risk of relapse and/or recurrence of a psychological disorder or apsychiatric illness in the mother and/or father;

Reducing inappropriate referrals and readmissions to adult psychiatric wards and the length of inpatient stays, and offering alternatives to admission;

Reducing the risk of self-harm, suicide and infanticide; Preventing avoidable separation of mother and baby and promoting early

return if separated; Facilitating admission to specialist Mother and Baby Psychiatric Units when

indicated

So in order to address issues of maternal mental health and promote stronger

maternal self-efficacy it is helpful to consider the options below.

Specific options for promoting infant mental health and parent psychological health

At the universal level, promote at every opportunity, in multiple settings, and in particular through Children’s Centres, how families can support the development ofemotional health in their babies and toddlers.

At a universal level and across the early years workforce, promote an awareness of:o the importance of the parent/baby relationship and how this will influence the

baby’s brain development, and


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o how interventions aiming to promote positive and healthy care givingrelationships need to be based on a positive relationship between worker and parent.

As well as the routine 6-week of age assessment, screen for the factors putting infant mental health at risk:

o during pregnancy and o at age 3-4 months (when the focus would be on the quality of parent-child

interaction). When significant risk is identified, implement targeted preventive interventions,

through the provision of well-resourced specialist NHS (or high quality alternative) Perinatal Parent Infant Mental Health Service support as well as access to regular and skilled supervision.

Resources

Chapter 1 pa es 12-23

An excellent overview of Infant Mental Health programmes is available on:-1. www.health child.ucla.edu/PUBLICATIONS/IMH Evidence Review FINAL.pdf

Also http://www.IMHPromotion.ca/

For adult mental health, useful both as information and handouts, this is a ve ood site: -1. www.cmha.bc.ca/resources/primer

There are a number of specialist sites coverin specific issues, e. .:-1. Autism - www.exploringautism.org2. Infant massa e - www.iaim.or .uk3. www.brazelton.co.uk

In the U. K. the leaflets once produced by the Child Psychotherapy Trust are now available online to bedownloaded.1. www.understandin childhood.net2. www.docsfortots.or is also worth a look ust for the name as well as bein a source of ideas.

ain, the Department of Health new information service for parents provides information delivered direct toparents as well as via professionals, usin website, e-mails and short video clips. https://www.nhs.uk/InformationServiceForParents/pages/home.aspx

For information on downloadin a si n-up wid et and addin it to our website emailsuppo nformationserviceforparents.nhs.uk

A3 – Assessing social and emotional development

A3.1 – Identifying risk factors in families in pregnancy and 0-2

o The Healthy Child Programme mandates: ‘A full health and social care assessment of

needs, risks and choices by 12 weeks of pregnancy by a midwife or maternityhealthcare professional’. Risk factors identified include young parenthood; parents who are not in education, employment or training; families who are living in poverty; unstable partner relationships.

http://www.imhpromotion.ca/

https://www.nhs.uk/InformationServiceForParents/pages/home.aspx


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o There is some evidence that positive bonding between mother and foetus duringpregnancy predicts the quality of bonding post-birth (Cremona 2008, Fonagy et al 1991), making poor maternal-foetus bonding a further risk factor.

There are opportunities for midwives to help parents prepare for the baby’s arrival during

pregnancy and to promote optimal bonding during and in the days after delivery. So in order to identify better where early help and support is needed in the most vulnerable families during pregnancy the following options might be considered in relation to updatingmidwifery and health visitor integration:

Some parents-to-be will fall under consultant- (obstetricians and paediatricians) rather than midwifery-led care and the corresponding care pathway will often involve medical procedures, lengthier hospital stays and potentially pre-term babies. It may be helpful to include these staff in understanding the neurology, attachment theory and developmental psychology for parent and infant as there could ultimately be greater risk in this group.

Specific options for Midwives in relation to social/emotional development

Carry out a mental health risk assessment as early in pregnancy as possible, coveringnot only depression and anxiety but chaotic lifestyle, domestic violence, drugs, alcohol etc.

As part of the risk factor assessment, the midwife enquires about the mother’s

perceived relationship with her family and her partner and the mother’s ‘bonding’

with the foetus. Recommended assessment tools: Edinburgh Post-Natal Depression Scale or the

Hospital Anxiety and Depression Schedule. Following appropriate training, both midwife and health visitor can carry out the short

form of the Neonatal Behavioural Assessment Scale, called the Newborn Behavioural Observation, in the presence of the parents at post-natal home visits in the first 3 weeks after birth. This will help both parents and practitioners to be able to read ababy’s signals and cues.

The care pathway for those women identified as being at risk should ideally include:o an early referral by the midwife to the local health visiting teamo a minimum of two promotional visits by the health visitor to the woman

before the baby is born to create a continuous pre- and post-birth relationship between health visitor and ‘at risk’ mother, as in the Family Nurse Partnership

in addition to the current handover from midwife to health visitor around 10-14 days after the birth.

It is important that all practitioners have an awareness of the risk factors that canjeopardise infant mental health. It is also crucial that the Healthy ChildProgramme be implemented fully in order to improve and deliver mental health promotion and respond to those families where children are not being adequately supported / protected on a pathway to secure attachment by ensuring that health visitors are resourced and trained fully in social/emotional assessment.


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Specific options for health visitors in relation to social/emotional development

Health visitors should be trained in the use of Motivational Interviewing for use from first contact onwards. This would help them to re-visit areas of risk outlined duringthe early pregnancy and discuss these areas of vulnerability with the mother and (ifappropriate) her partner.

Professionals such as health visitors should be trained to evaluate the interaction between the mother and baby (ideally by using a short video clip, which can also be used in reflective video feedback discussions with the parents).

Health visitor assessment at 3-4 months could use the ‘Parent Infant Interaction Observation Scale’ (a 13 item scale used to guide the assessment and evaluation of avideo of a brief parent-infant interaction). Currently the planned web-based trainingfor this scale is not available although the group based training now is. Alternativescales would be assessment tools like ‘Keys to Interactive Parenting Scale’ and the ‘CARE-Index’.

Introduce an assessment of attachment behaviour at age 12-15 months using the TAS-45 measure as outlined in the Conclusions above.

Resources


See information on Toddler Attachment Sort - 45 (TAS-45), http://www.acf.hhs. ov/pro rams/opre/ehs/perf_measures/reports/resources_measurin /res_meas_cdiqq.html

The Association of Infant Mental Health is open to an one with a professional interest in ve oun children. www.aimh.org.uk

Some websites to be in lookin for information on how the quali of the earl care ivin relationship sculpts thebrain, fo ood or ill, are:-1. www.brainconnection.com2. www.macbrain.o3. www.zerotothree.o ww.zerotothree.or /bab -brain-map.html4. www.dana.o

Attachment theo has provided the basis for much research and clinical work in Infant Mental Health. Someinformative websites to look at are:-1. www.childandfamil studies.leidenuniv.nl/index.php3?c=672. www.psychology.sunysb.edu/attachment3. www.turnerto s.com/4. www.attachmentnetwork.or5. 128.121.62.12/Marvin_Evid_Tx.htm6. http://www.iasa-dmm.org/

Youn Minds have launched an Infanc Polic , and also a ood leaflet on ‘Tunin in to Our Babies’ 003 . www. oun minds.o .uk/infanc polic /

ArticleScience Does Not Speak for Itself: Translatin Child Development Research for the Public and Its Polic makers, Child Development, Janua /Februa 2011, Volume 82, Number 1, Pa es 17–32

http://www.psychology.sunysb.edu/attachment


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A4 – Family violence and neglect

o It is reported that around 25% of children witnessing domestic violence developserious social and behavioural problems.

o Being brought up in a home where parents are involved in domestic violence is among factors which make poor attachment more likely for infants.

o Children who witness domestic violence are at risk of physical injury during an incident, and will experience serious anxiety and distress which can later express itself in anti-social or criminal behaviour, or as psychological problems.

o Children in homes where there is domestic violence are at more than double the usual risk to suffer child abuse.

o In the past year 39,000 UK babies under a year of age lived in households affected by domestic violence.

o A number of studies suggest there can be an increased incidence of domestic violenceduring or shortly following pregnancy (e.g. a survey of 1207 women attending GP surgeries in Hackney found pregnancy in the past year associated with an increased risk of current violence).

o Domestic violence can seriously impact the parenting capacity of the victim.

So in order to ensure more action is taken to prevent both domestic violence and children’s witnessing of it, the following should be considered;

Specific options on domestic violence

Make it a priority for midwives, GPs and other health professionals to identify and provide family support where domestic violence is identified as a risk in pregnancy.

Ensure that local police forces have robust procedures in place not only to deal with individual incidences of domestic violence but also to have the intelligence and data systems to identify emerging patterns.

Domestic violence support services for both victims and offenders should prioritise families where the woman is pregnant, or there is a baby under 2 years of age.

Resources


For an introduction to the lon term neurolo ical and ps cholo ical consequences of earl trauma:-1. www.childtrauma.or2. www.trauma- s.com3. dynamic.uoregon.edu/~jjf/aaas04/PutnamAAAS%20.pdf

And for ideas on how to help:-1. www.futureunlimited.o2. www.nctsnet.org3. www.nccev.o

http://www.nccev.org/


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A5 – Improve parenting capability

o Many proven early childhood programmes demonstrate substantial net economicbenefits, including savings to the public purse, particularly through better long-term health and crime reduction. Some experts, e.g. Professor James Heckman, assert that the highest return come from interventions at the earliest ages. Evidence also suggests:

Best effects are delivered when support is provided to follow up the familylonger term.

Most significant effects are found for groups with a large number of risk factors.

o Although non-UK evidence does not necessarily translate directly to the UK (becausewe already have universal maternity and perinatal health provision in the form of the Healthy Child Programme), where UK evaluations do exist (e.g. Croydon Total Place, the Millennium Cohort Study, the LSE evaluation of programmes to reduce conduct disorder, and others listed in the appendix on UK economics), they suggest very good economic returns, several times higher than costs, for early years’ investment in a UK

context.

So in order to intervene early to promote infant mental health and to reduce the risk of children’s development being hampered by abuse, neglect or other early parent-child relationship difficulties, thereby reducing the risk of longer term poor outcomes which entail higher longer term costs, local investment needs to be targeted at early investment in

locally delivered evidence-based programmes:

Specific options to improve parenting capability

Invest in proven, effective (and cost-effective) programmes such as the Circle ofSecurity; Family Nurse Partnership; First Steps in Parenting; models like theSunderland Infant Project; and Watch, Wait & Wonder.

A comprehensive review by Barlow et al219 found that those parenting programmes which do not consider cultural factors risk poor engagement and drop-out of BME parents. The Policy Research Bureau220 concludes there needs to be an awareness and respect for different models of parenting that arise within different cultures, and the need to tailor programmes accordingly; while at the same time recognising thecommonalities of parenting within different cultures.


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Some examples of parenting programmes

Programme Description

Incredible ears The Incredible Years are research-based, proven effectiveprogrammes for reducing children's aggression and behaviour problems and increasing social competence at home and at school.

Infant Behavioural Assessment Intervention Programme

A home-based pro ramme offerin support for parents of vepreterm infants.

Famil Links Nurturin Pro amme The Nurturin Pro ramme provides simple, effective tools to helpadults and children understand and mana e feelin s and behaviour, improve relationships at home and in school, improve emotionalhealth and wellbeing, develop self-confidence and self-esteem. Theparentin pro ramme is a 10 week course of 2 hours per week, for children from birth to 18.

Mellow Parenting Offers evidence based parenting programmes which have beenshown to be effective in improvin mother child interaction, childbehaviour problems, mother’s well- bein and mother’s effectivenessand confidence in parenting.

Triple P Triple P is a parenting and family support strategy that aims toprevent severe behavioural, emotional and developmental problemsin children b enhancin the knowled e, skills and confidence of parents.

Health Eatin and Nutrition for the Really Young (HENRY)

Parentin and Relationship issues are tackled as part of an award-winning programme focused on obesity.

The Family Partnership Model The Family Partnership Model is an innovative approach based uponan explicit model of the helpin process that demonstrates howspecific helper qualities and skills, when used in partnership, enableparents and families to overcome their difficulties, build stren ths andresilience and fulfil their goals more effectively.

The Solihull Approach The Solihull Approach is based on the Solihull Approach Model of Containment, Reciproci and Behaviour Mana ement. It is intendedfor parents and carers who want to know more about sensitive and effective parenting.


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ResourcesChapter 1 pages 14-23

Universal parentin classes: the DfE CANparent Trial is seekin to stimulate a market in universal classes so that over time an parent could access such a class. It is throu h stimulation of a national market, drawin on variousfundin models, includin parents pa in for the full or partial cost of classes, that this vision could be achieved. Evaluation of the trial, 2012-14, will provide learnin on the feasibili of this. Providers in the trial were requiredto demonstrate that their work conformed to evidence-based principles.

The commissionin toolkit of parentin pro rammes is a searchable database of parentin interventionsdesi ned to provide information and uidance for commissioners, service mana ers and pro ramme developerson the quality and effectiveness of parenting programmes/approaches.https://www.education. ov.uk/publications/eOrderin Download/Commissionin _Toolkit_user_ uide.pdf

Preparation for Birth and Be ond is an antenatal education pro ramme based on a s stematic review of the evidence of what works in antenatal education carried out by the University of Warwick, and extensiveinterviews with a broad cross-section of mothers and fathers-to-be and new parents. Some of the learnin fromthe Famil Nurse Partnership pro ramme has fed into the desi n of this work. http://www.nct.o .uk/professional/antenatal-services/preparation-birth-and-be ond-antenatal-education-programme

This aims to help the NHS, local authorities and the volunta sector in plannin or runnin roups for expectant and new parents. It is a practical tool that aims to improve outcomes for babies and parents and covers thephysiological aspects of pregnancy and birth, and also addresses the emotional transition to parenthood, childdevelopment, the roles and experiences of both parents and relationship issues in greater depth.

http://www.dh.gov.uk/health/2011/10/preparation-for-birth-and-beyond-resource-pack-to-help-parenthood-groups/

DH Birth to Five /NHS Choices - Some useful advice relevant to difficult behaviours e.g. tantrums etc.http://www.nhs.uk/Planners/birthtofive/Pa es/Understandin difficultbehaviour.aspx

KidCareCanada Socie translates current research and applies technolo to produce educational resourcesrelevant to the 21st Century new parent. The accessibility of these resources enables all children to have equalo ortuni to the best ossible start in life, and romotes the health, ha iness and well-bein of future

enerations. http://kidcarecanada.or /

Attachment Parenting International - Attachment Parenting International (API) promote parenting practices thatcreate stron emotional bonds between child and parent. API believe that Attachment Parentin practicesfulfill a child’s need for trust, empath , and affection, providin the foundations for lifelon health relationships. Attachment Parentin has been studied extensivel for over 60 ears. Studies revealed that infants are born‘hardwired’ with stron needs to be nurtured and to remain ph sicall close to the prima care iver. Theseneeds can be summarized as proximity, protection, and predictability. http://www.attachmentparentin .o /principles/intro.php

Best Be innin s - Video clips for parents re bondin , Infant communication and pla videos and commentafrom clinical psychologist Dr Liz Kirk. http://www.bestbeginnings.org.uk/bonding-before-birth

Parentin UK - Excellent search en ine which lists 36 resources on attachment and 9 on infant mental health. Professionals’ and parents’ materials.

World Association for Infant Mental Health WAIM - promotes education, research and stud of the effects ofmental, emotional and social development durin infanc on later development throu h international andinterdisciplina cooperation, publications, affiliate associations, and throu h re ional and biennial con resses. www.waimh.org

The Mindful Polic Group - dedicated to a more humane, carin , and ps cholo icall aware socie . www.mindfulpolic roup.com

Be in Before Birth - What happens in the womb can last a lifetime. The influence of the environment be ins inthe womb, this environment can have a lastin effect on development. www.be inbeforebirth.o

What About The Children? - ‘Raising Awareness about the Emotional Needs of Under 3s’. http://www.whataboutthechildren.org.uk

http://www.dh.gov.uk/health/2011/10/preparation-for-birth-and-beyond-resource-pack-to-help-parenthood-groups/

http://www.whataboutthechildren.org.uk/


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‘Talk to Your Bab ’ run b The Literac Trust encoura es arents to talk more to children from birth to 3 ears. www.literacytrust.org.uktalktoyourbaby

The Communication Trust - highlights the importance of speech, language and communication across thechildren’s workforce. www.thecommunicationtrust.org.uk

Mellow Parentin - deliverin quali trainin in evidence based parentin pro rammes multi-nationall . Traininis delivered to local authori and NHS Staff as well as volunta a encies workin with the most vulnerablefamilies in society. www.mellowparenting.org

I CAN - The Children’s Communication Charity www.ican.org.uk

Parent Infant Clinic - Emotional screenin of all babies under 1 ear; trainin professionals in si ns of autism ininfants and treatment; to help pa for treatments of babies that have serious si ns of autism. www.infantmentalhealth.com

International Pre-Autistic Network pan - roup of ps choanal ticall informed clinicians and researchers whocome together for ideas, opinions and insights www.ipan-babies-autism.org

Center On The Developin Child - Harvard Universi - Drawin on the full breadth of intellectual resourcesavailable across Harvard Universi ’s schools and hospitals, the Center enerates, translates and appliesknowledge in the service of improving life outcomes for children in the United States and worldwide.

http://developingchild.harvard.edu/

The Marce Socie - An international socie for the understandin , prevention and treatment of mental illnessrelated to childbearing www.marcesociety.com

Children in Scotland - The national agency for voluntary, statutory and professional organisations and individualsworking with children and their families in Scotland. www.childreninscotland.org.uk

Zero to Three – American website fo eneral information on development from the ante-natal period to 3 ears. It includes details of different wa s of offerin earl intervention, both home and centre based. Their bi-monthljournal is essential reading. www.zerotothree.org

And for eneral research-based information on this period:-www.isisweb.org

http://www.dad.info/

http://www.infantstoteens.com

Links to parentin interventions outlinin how the should be tailored in such a wa as to respect and not undermine the cultural values, aspirations, traditions and needs of different minori ethnic roups.

http://www.rbkc.gov.uk/pdf/parenting_literature_review.pdf

http://www.jrf.org.uk/sites/files/jrf/barriers-inclusion-parents.pdf

http://www.prb.org.uk/wwiparenting/RR574.pdf

http://ethnos.co.uk/DCSF-Engaging%20effectively%20with%20BME%20parents.pdf


http://www.ipan-babies-autism.org/

http://www.isisweb.org/

http://www.dad.info/

http://www.infantstoteens.com/

http://www.rbkc.gov.uk/pdf/parenting_literature_review.pdf

http://www.jrf.org.uk/sites/files/jrf/barriers-inclusion-parents.pdf


http://ethnos.co.uk/DCSF-Engaging%20effectively%20with%20BME%20parents.pdf



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B – QUALITY OF EARLY YEARS’ SERVICES

B1 – Multi-agency working

o The Marmot Review indicated that effective multi-agency practice to address a rangeof social determinants of poor health was key to improving outcomes, and to givingchildren the best start.

o Children in families which suffer a number of different disadvantages or risk factors are disproportionately likely to suffer long term poor outcomes. The patterns of their problems or disadvantages vary a great deal, so services need to be flexible enough to support families whatever their varied circumstances and sets of issues, withoutpassing them to lots of different agencies.

o Children’s centres provide access to a wide range of services including family and employment support, and help with housing and financial problems. Evidence also suggests that early intervention by midwives or other health engagement at children’s

centres can lead to a direct reduction in young children's risk of poor outcomes including:

reduced incidence of low birth weight and of foetal and postnatal injury improved uptake of preventive health care a lower risk of poor bonding and attachment reduced child neglect and abuse

o There are some examples of excellent multi-agency working, such as the Integrated Services model in Highland Region of Scotland221 and some of the health visitor, children centres and school nurse local integrated partnerships (Warwickshire, Brighton and Hove, East Lancashire health coordinator team, Bowthorpe, West Earlham and Costessey children’s centres).

So in order to build on and develop effective multi-agency, integrated workingand delivery to ensure that services are working together, sharing information and communicating with each other and with parents and carers, to achieve positive outcomes for children, local areas might consider:

Options

Developing effective multi-agency working and delivery through identifying and following the principles of such highly successful multi-agency practices as the Highland Region Streamlined Rapid Reaction system, and case studies from the LGA knowledge hub and DH early implementer sites.

Accessing Children’s Improvement Board support materials to promote integrated working and learn from the 18 development demonstrator sites using whole system approaches to effective integrated working.

Explore the potential of linking in with local interventions around the Troubled Families initiative, especially where the focus is on working through a single keyworker and dealing with problems in a more holistic way.


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Resources

Chapter 2 pages 24–28 and 32-36

Children’s centres and health visitors: unlockin the potential to improve local services for families: A report from the HV partnership delivery group task and finish group 2012

HandsOnScotland - The website provides practical information and techniques on how to respond helpfull tochildren and oun people’s troublin behaviour, build up their self-esteem and promote their positive mentalwellbeing. www.handsonscotland.co.uk

1. www.touchpoints.or2. www.childdevelopmentinfo.com3. www.educarer.com4. www.familyresourcecentre.com5. www.indiaparentin .com6. www.fnih.investinkids.ca/7. www.kidshealth.or8. www.incredibleyears.com

Harvard USA http://developin child.harvard.edu/index.php/resources/multimedia/interactive_features/biodevelopmental-framework/

B.1.1 Children’s Centres

Recent evaluations show that Sure Start Local Programmes (SSLPs) have successfullyengaged the most vulnerable groups in the most deprived areas, though it often takes considerable time to encourage vulnerable families to engage with services. The earlySSLPs had beneficial effects on parenting which persisted until the children were age 7. The benefits of SSLPs appear to apply to all areas regardless of level of deprivation, and to all children and families regardless of family deprivation. However, there was no evidenceof sustained beneficial impact on child outcomes – reinforcing the need to ensure that allprovision in children’s centres is evidence based.

Children's Centres provide integrated services that can support the most disadvantaged children and families. The challenge is to make the most of this in a way that measurablynarrows the gaps in outcomes between less and more advantaged children. So in order to ensure that the national network of Sure Start Children’s Centres is well placed to engage the most vulnerable groups and support them effectively, local commissioners might consider:

Specific Options for Children’s Centres

Prioritise high quality outreach and family support to work with the most vulnerable families suffering multiple risk factors, who may need long-term work to get them to the point of accessing other services.

Clearly defined roles for health visitors in leading services and/or teams within children’s centres (where capacity allows)

http://www.handsonscotland.co.uk/


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o Explore the potential for health visitors to act as team leaders, supervisors, and/or mentors, building capacity and skills within the children’s centre team and

contributing to better integrated delivery and improved information sharing Explore the potential for shared local targets to help drive and incentivise integrated

deliveryo Develop local measures of success for children’s centres (not necessarily for

payment by results) which link to those in the Children and Young People’s

Public Health Outcomes framework and the Healthy Child Programmeo Develop truly integrated assessments and reviews (two year/two and half year

integrated review)

In order to have a greater direct impact on outcomes: o Give greater emphasis to services that will improve child outcomes, including

proven evidence based parenting programmes and support for social and emotional and language development;

o Focus more directly on improvements to what young children experience in theirdaily lives: at home and in children’s centre settings.

Resources


The outreach s stem leaders report on evidence-based outreach pro rammes. National Colle e.

DH Health Visitor partnership delive roup report- Children centres and health visitors: unlockin the potentialto improve local services for families.

Specific Options for other early years settings

Understand attachment

o practitioners should have a good understanding of attachment as it relates to thechild’s key relationships and their own relationship with the child

o practitioners should be able to build warm, responsive and sustained relationships with young children confirmed by visual, auditory and physical contact

o continuity and consistency of primary care is important e.g. key person systems. The revised EYFS statutory framework for the early years’ foundation stagerequires providers to assign a key person to every child to ensure that everychild’s care is tailored to meet their own individual needs, to help the child

become familiar with the setting, offer a settled relationship for the child and build a relationship with their parents.

B2 – Workforce

A good understanding of child development from pre-birth to age 3 can help early years practitioners to work more effectively with young children and their families This is likely to include an understanding of:


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o Social and emotional development;o Age-appropriate expectations;o Early brain development;o Cultural, social and emotional factors that contribute to common behavioural

problems in young children;o The importance of a preventive approach (recognising the need to intervene early to

prevent escalation of concerns and/or maltreatment).

For early years practitioners dealing with vulnerable families or babies, emotional intelligence is important to enable them to build resilience to:

o deal with the emotionally demanding aspects of their work ando create positive, non-judgmental relationships with the members of the family

involved.Practitioners working with infants and their families can be supported through appropriatetraining and support, which good practice from the FNP work suggests should include areflective space with a supervisor, coach or mentor, to understand and process their work. Whatever the training option selected, the central focus of the work is upon the quality of therelationship between the practitioner and the family.

Specific Options on Workforce

Consider recruitment processes for early years practitioners which assess:o Emotional intelligence;o Knowledge and skills on interactions with infants and toddlers;o Knowledge and skills of child development from pre-birth to 3 years;o Interface with Safeguarding knowledge;o Skills to form empathic relationships with parents.

Consider providing personal support programmes for workers which recognises the emotional impact of the work and the impact of personal issues for the supervisee and ensuring that the supervisee has emotional intelligence.

Consider whether staff in all early childcare and other early years’ settings have a

good understanding of child development and how to spot and tackle problemsappropriately and quickly.

Support effective parenting. It is critical that the workforce has the skills to offer evidence-based interventions, including parenting programmes, where appropriate.

Understand the importance of speech and language development. It is recognised that Personal, Social, and Emotional Development, Communication and Language, and Physical Development are prime areas of learning for our youngest children.


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Resources

Chapter 2 pages 32-36

For more information on EYFS two web links are helpful:http://www.education.gov.uk/schools/teachingandlearning/curriculum/a0068102/early-years-foundation-stage-eyfs hich is the EYFS section of the DfE site and includes, in addition to the EYFS, Development Matters(covering 0-5 development)andhttp://www.foundationyears.org.uk/early-years-foundation-stage-2012/ hich links to the 4Children-runFoundation Years website also full of relevant resources for 0-2

http://www.education.gov.uk/childrenandyoungpeople/earlylearningandchildcare/delivery/b00201475/working

DfE has contracted the Earl Lan ua e Consortium, led b I-CAN, the children's communication chari , todeliver a 3 ear Earl Lan ua e Development trainin Pro ramme throu h children's centres for people workinwith young children. This builds on the Every Child a Talker programme which ended in March 2011. It willprovide a suite of trainin , resources, tool kit and strate ies ta eted at practitioners to support children andparents. http://www.education.gov.uk/childrenandyoungpeople/earlylearningandchildcare/delivery/education/a00212432/eldp

DH is currentl workin with The Centre for Workforce Intelli ence WI to look at the issue of thecompetencies required b the ps cholo ical workforce sp IAPT and includin alsopsychotherapists, counsellors and GPs) http://www.cfwi.org.uk/workforce-planning-news-and-review/psychological-therapies-workforce-review

Much of the evidence is endurin , http://www.longtermventilation.nhs.uk/_Rainbow/Documents/Children%27s%20national%20workforce%20competence%20framework.pdfhttp://www.home-start.org.uk/about/A_beginners_guide_to_children_and_families_workforce_development.pdfThis is a helpful link to effective supervision http://ec.europa.eu/education/more-information/doc/2011/coreannex_en.pdfhttp://www.faculty.londondeanery.ac.uk/e-learning/supervision/principles_underpinning_effective_supervison.pdf

C – PROMOTION OF EARLY YEARS’ PRIORITY

C1 – Evidence-based interventions

A range of American evidence suggests a strong economic case for greater investment in specific early intervention programmes which have been evaluated to show substantial net long term benefits. The evaluation of the Family Nurse Partnership in England is beginningto provide promising findings, suggesting that at least some of the benefits found byAmerican studies can be replicated in the UK. A number of parenting programmes and otherearly years’ interventions have also been shown to demonstrate substantial benefits in a UK

context.

Commissioning evidence based programmes requires a good understanding of:o the needs of the local population;o which approaches / programmes are likely to be most effective in addressing them,

based on evaluation and other evidence of effectiveness elsewhere;o costs and ease of implementation (not all effective programmes are readily available

in the UK)

http://www.education.gov.uk/schools/teachingandlearning/curriculum/a0068102/early-years-foundation-stage-eyfs

http://www.education.gov.uk/schools/teachingandlearning/curriculum/a0068102/early-years-foundation-stage-eyfs

http://www.foundationyears.org.uk/early-years-foundation-stage-2012/

http://www.education.gov.uk/childrenandyoungpeople/earlylearningandchildcare/delivery/b00201475/working

http://www.education.gov.uk/childrenandyoungpeople/earlylearningandchildcare/delivery/education/a00212432/eldp

http://www.education.gov.uk/childrenandyoungpeople/earlylearningandchildcare/delivery/education/a00212432/eldp

http://www.cfwi.org.uk/workforce-planning-news-and-review/psychological-therapies-workforce-review

http://www.longtermventilation.nhs.uk/_Rainbow/Documents/Children%27s%20national%20workforce%20competence%20framework.pdf

http://www.longtermventilation.nhs.uk/_Rainbow/Documents/Children%27s%20national%20workforce%20competence%20framework.pdf

http://www.home-start.org.uk/about/A_beginners_guide_to_children_and_families_workforce_development.pdf

http://ec.europa.eu/education/more-information/doc/2011/coreannex_en.pdf

http://ec.europa.eu/education/more-information/doc/2011/coreannex_en.pdf

http://www.faculty.londondeanery.ac.uk/e-learning/supervision/principles_underpinning_effective_supervison.pdf


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The most effective programmes have been shown to have a positive long-term impact on outcomes, and potential savings to existing local services. But delivering these benefits depends on very good targeting of those resources, and effective implementation: the moreyou vary from an existing highly evaluated programme, the less likely, in general, you are to deliver the same benefits in your area. So effective local monitoring and evaluation areimportant to improve continually the effectiveness of services.

Resources


Economic theorieshttp://www.ncsl.org/issues-research/human-services/new-research-early-education-as-economic-investme.aspx

The commissionin toolkit of parentin pro rammes is a searchable database of parentin interventionsdesi ned to provide information and uidance for commissioners, service mana ers and pro ramme developerson the quality and effectiveness of parenting programmes/approaches.https://www.education.gov.uk/publications/eOrderingDownload/Commissioning_Toolkit_user_guide.pdf

C4EO- provides a ran e of support to drive positive chan e in the delive of children’s services. One of thepriority areas for c4eo is early intervention. www.c4eo.org.uk

OXPIP - The Oxford Parent Infant Pro ect - http://www.oxpip.o .uk/

C2 – Health

Specific Options for Health and Wellbeing Boards

Consider prioritising infant mental health and factors of importance to infant wellbeing in the Joint Strategic Needs Assessment, because of the long term positive impact on wider outcomes.

Learn from effective Children’s Trust arrangements in the new commissioning

process with Health and Wellbeing Boards in setting local priorities for children through the JSNA.

Provide clear information to health practitioners about the importance of measures supporting children from pregnancy to age 2, and their parents.

Recruit a Public Health champion to advise local areas on how best to incorporate theimportance of 0-2 s into the JSNA and provide advice to the whole public health community and especially commissioners of early years’ health services on the

importance of the period birth to two with respect to long term public health outcomes.

Specific options for health commissioners The Healthy Child Programme needs further development of detailed clinical

guidance (as was completed with the Two Year Review) for earlier ages (e.g. first year of life) so that it can be commissioned and disseminated in a similar way. This development would include expanding assessment of attachment and specialist

https://www.education.gov.uk/publications/eOrderingDownload/Commissioning_Toolkit_user_guide.pdf


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pathways, parental and infant mental health, drug and alcohol, domestic abuse, relationships, and links to 'Pregnancy, Birth and Beyond'.

For health visitors, consider use of the high quality e-learning training modules as part of the Healthy Child Programme – which cover secure attachment, parent and infant mental health, domestic violence, drugs and alcohol, links to pregnancy. For midwives, consider high quality training modules on stress, domestic violence, drugs and alcohol, assessment of risk and links to Health Visitors. This resource was originally launched by Ann Milton and is available to all NHS staff free of charge.

Resources

For examples of ood local practice in earl ears and useful information and advice for local authorities andothers visit www.c4eo.o .uk/

The curriculum and a link to the HCP e-learnin resources for all healthcare staff http://www.e-lfh.or .uk/pro ects/health child/index.html This work was commissioned b the Department of Health anddelivered b e-Learnin for Healthcare e-L n collaboration with a consortium of professional bodies.

DH Earl Implementer Siteshttp://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Aboutus/Features/DH_125650

C3 – Communications – Conclusions

The most effective way to raise awareness of the importance of very early life and, therefore, how we support pregnant parents is to use a multi-channel approach, with a range of keycredible spokespeople. The timing of the message needs to have resonance with the stage of life and proximity of behaviour of the target audience to have effect.

o Well educated and informed health and social care professionals can have an extremely powerful impact on outcomes (as testified by the results from FNP).

REFERENCES (For local commissioning framework)

Secure attachment215 Comfort, M., Gordon, P.R., English, B., Hacker, K., Hembree, R., Knight, R., & Miller, C. (2010). Keys to InteractiveParenting Scale: KIPS Shows How Parents Grow, Zero to Three Journal, 30(4), 33-39.216Crittenden, P. M. (1988). Relationships at risk. In Belsky, J. & Nezworski, T. (Eds) Clinical implications of attachment. Hillsdale: Lawrence Erlbaum Associates, 136-176.217 Benoit, D., Madigan, S., Lecce, S., Shea, B., & Goldberg, S. (2001). Atypical maternal behaviour toward feeding-disordered infants before and after intervention. Infant Mental Health Journal. 22(6), 611-626218 Vik, K. & Braten, S. (2009) Video interaction guidance inviting transcendence of postpartum depressed mothers’ self-centred state and holding behavior. Infant Mental health Journal, 30(3), 287-300

Improving parenting capability219 Barlow, J., Shaw, R., Stewart Brown, S. & REU. (2004). Parenting Programmes and Minority Ethnic Families: Experiences and Outcomes. London: National Children’s Bureau220 Moran, P., Ghate, D. & van der Merwe, A. (2004). What Works in Parenting Support? A Review of the International Evidence. London: Policy Research Bureau & Department for Education and Skills

Multi agency working221 For Highlands Children. (2012). A gateway to Children's Services across Highland. Available: http://www.forhighlandschildren.org/.

http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Aboutus/Features/DH_125650


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APPENDIX 1 –

Mental Health Promotion in children under the age of two

Mental Health Promotion

o The World Health Organisation defined mental health and mental health promotion as follows: Mentalhealth is a state of well-being in which the individual realises his or her own abilities, can cope with thenormal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.

o Mental health promotion is an umbrella term that covers a variety of strategies, all aimed at having apositive effect on mental health. The encouragement of individual resources and skills andimprovements in the socio-economic environment are among them (WHO, 2001).

The linkages between emotional, social and physical health

Emotional, physical and social health are interlinked and interdependent.

Social health

Emotional/mental health Physical Health

Failure to promote the secure relationships that underlie emotional health in infancy has a direct result onemotional, social and physical health, both in childhood and in the longer term. By promoting mental health in thefirst few years of life, beginning in pregnancy, society ensures that as many children as possible grow up toembrace social, physical and emotional health as adolescents and as adults. Positive pre-verbal healthfoundations are directly related to positive relationships within the family and within the family’s environment.

Infant mental health within a Positive Health Promotion framework

Infant mental health is synonymous with healthy social and emotional development across the life course. Theemotional environment of infancy, which from the baby’s point of view consists of relationships with the parents,

will be preserved on both a psychological and neurological level for good or for ill depending on the quality of that environment. On this foundation all future experiences will be built.

The most essential factors for positive infant mental health are: active, satisfying and reciprocal relationships withparents, which create the ‘taken for granted’ basis of a sense of identity; self-esteem; appreciation of others, andself-control.

It is now known that the developing brain of the baby adapts itself, on a neurobiological level, to the quality of thecaregiving environment. Good quality relationships and secure attachment enable a growing brain to becomesocially efficient and so provide the biological basis for future self-control and cognitive development; whereas abrain marinated in maltreatment will carry what were once necessary responses to a hostile environment for therest of life.

The central importance of children’s first significant relationships

Secure attachment, although not a guarantee of future mental health, is a protective factor, conferring confidenceand adaptability, along with the emotional competence and benign interpersonal expectations needed to deal

Positive parent-baby relationships


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with loss or trauma should they occur in life. Secure children and adults are resilient, are able to regulate their emotions, have developed empathy and can self-repair when stressed or challenged. Insecure attachment organisation, on the other hand, creates a significant vulnerability that, together with stressful life events andconcurrent vulnerability factors, can create a spiral of ‘deviation amplification’ which eventually will lead to

psychological or psychiatric symptomatology.

Secure attachment between infant and caregiver is promoted by sensitive and thoughtful parenting, where thebaby can be held in mind and caregiving is not compromised by negative influences (see the risk factor check list in Appendix 2C). The quality of these first relationships will directly affect the development of the baby’s brain.

Early social and emotional development in a public mental health context

There are significant and expensive public health consequences stemming from poor infant mental health at apopulation level. All forms of insecure attachment create negative susceptibility that will interact with other riskspresent in the emotional and physical environment of the growing child; the level of attachment disturbance isequivalent to a level of vulnerability that is difficult to change without help. Children with problems related to veryinsecure attachment begin to soak up statutory resources from early on when ‘externalising’ behaviour

(aggression, non-compliance, negative and immature behaviours, etc.) demands a response from society.

From a life-path perspective it has been demonstrated that children who have suffered early neglect and abuseare far more likely to suffer from serious physical and mental illnesses when they are adults, thus taking up anexcessive and disproportional amount of health service resources, and they are also at a greatly increased risk of early death. Children who develop strategies of compulsive compliance (as opposed to the more usual tactic of controlling and violent behaviour) as a response to abuse may become ‘invisible’ until this protective strategy

collapses in adolescence.

Therefore, infant mental health must be seen as everyone’s business; babies can neither wait nor stand up for

themselves. It is a requirement of the UN Convention on the Rights of the Child that their wellbeing is protected.

The consequences of maltreatment and adversity in infancy

What is technically known as ‘disorganised’ or ‘complex’ attachment is the most serious form of insecure

attachment. This may often occur when, for whatever reason, a caregiver has no mental space left over for their baby or, more gravely, poses some sort of threat through being frightening, fearful or out of touch.

Children who have been maltreated in the early years, most of whom will demonstrate disorganised attachment, end up with a ‘wired in’ compromised ability for self-control, and a lack of coping mechanisms on a neurologicallevel for dealing with internal and external stresses and frustrations, which confer a high vulnerability for later emotional, relational and mental health problems.

Infants who have suffered adverse relationships frequently go on to become teenagers and adults who aregrossly over-represented in the criminal justice system. This is not only a direct drain on resources; it alsosignifies a large population who are not in a position to contribute to the wider society (the same applies to thosewho never leave their dependency on mental health provision).

The importance of early intervention services

Early intervention, where vulnerable and highly stressed parents can be identified and supported before the babysuffers, is an essential preventive service if we want to avoid a steady growth in the number of referrals to adult health services and the criminal justice system.

A comparatively small proportion of the funds allocated to adult mental health services now could reduce thisdrain on resources in the future if it were allocated earlier to preventive interventions in the early years.

Economic benefits of very early intervention (see also Appendix 4)

A number of studies demonstrate the long-term cost benefits of helping vulnerable families provide the sort of emotional environment for their babies and toddlers that leads to secure attachment.

The expense of not intervening is in the direct and indirect costs of later anti-social behaviour, mental ill health or another generation struggling to offer ‘good enough’ parenting in turn.


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Simply preventing the occurrence of early child maltreatment or, if that has been impossible, offering prompt andappropriate treatment, has a long-term benefit that is enormous in terms of services that will not need to be calledupon to intervene in the child’s future.

The contribution of the Healthy Child Programme to mental health promotiondesigned to benefit babies and toddlers

The Healthy Child Programme (HCP) provides the framework for health visitor-led mental health promotion inpre-school children. Interventions may be at a universal or targeted level. Universal support to families in theHCP includes activities to promote the development of emotionally secure children and families by, for example, promoting the self-esteem of the parents, child-caregiver attachment and positive parenting practices. It alsoincludes working specifically with women experiencing postnatal depression or domestic abuse, with children withbehavioural problems, managing child abuse and bereavement. Providing it is done as a universal service, healthvisitors leading the programme must ensure the programme is delivered across many social and ethnicboundaries, and with excluded groups such as the homeless, travellers, asylum seekers and the families of prisoners, who face particular mental health challenges as a result of their life styles.

The multiple positive and negative emotional forces within the family that may affect a child’s future emotional health

(© Cheryll Adams, 2006)

Implications for early intervention

If the central relationship between the baby and parents is given the attention it deserves, it has two major implications:

o Firstly, many later emotional and mental health problems can be reworked only in a similar fire as forgedthem.

o Secondly, by recognising the parent-baby relationship is the crucible for change and development, for good or ill, we can see beyond the individuals to the wider conditions that impinge upon this relationship.


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Anticipating when caregiving will be jeopardised: a consideration of riskfactors

o The parent-baby relationship is always located in a wider context, within which are found both risk andprotective factors. Risk factors can harm the baby directly (e.g. pollution, substance abuse in pregnancy, unhealthy housing) but mostly are titrated into the relationship via their effects on the parents’ social and

emotional functioning, since these dictate the baby’s immediate emotional experiences.

o The information on risk factors allows babies who might be likely to have adverse developmentalpathways through life, because of stresses in their initial relationship with their parents, to be easilyidentified early on.

The greater the number of risk factors found in a family’s total ecology, the greater the need for immediateassistance and the longer term will be the time involved in helping and supporting them. The recognition andanalysis of risk factors clearly shows how external pressures can distort the relationships within a family.

How should mental health promotion in the early years be targeted?

o Through 3 levels – universal interventions, targeted preventive interventions and therapeuticinterventions addressing a problem.

o By considering the emotional and social health needs of the whole family as they will directly affect theemotional health of the infant.

o Through the use of available helpful policy and practice – particularly the need to implement fully theHCP.

o By promoting at every opportunity, in multiple settings, how families may promote secure attachmentand emotional health in babies and toddlers.

o Screening for the factors putting infant mental health at risk.

Characteristics of effective early intervention services for families with very young children as part of a policy of overall mental health promotion

o Any intervention, regardless of technique or theory, is only as effective as the quality of the relationshipsthe intervention team can build with the families.

o Programmes that aim to improve the relationship between parent and baby can deliver only if they areembedded within a ‘relationship-based organisation’ where the quality of the relationships within the

team match the quality they aim to foster within the families being supported.o Evidence supports the principle that proactive programmes, those that are truly preventive (and

therefore kindest), beginning either in the pre-natal period or at birth, have the greatest and mostsustained effect.

o The earlier we intervene, the better. Babies can’t wait.

o The best results are attained with strength-based approaches that focus on parental empowerment andinvolvement.

o This is highly skilled work that demands well-skilled, well-trained and well-paid staff who possess thecompetencies needed to gauge when and how to intervene.

o Children’s Centres are perfectly placed to deliver low stigmatising ‘wrap around’ services ranging from

health visitors and specialist infant mental health teams to the full gamut of the different parentinggroups available.

o Infant mental health services demand a core of specialised knowledge and skills congruent with thewide range of risk factors and developmental issues that need to be considered.

o Reflective supervision is essential to avoid the risk of defensive avoidance, vicarious traumatisation, counter-transference, collusion and burnout.

o Staff must be carefully selected for their emotional health as well as education and skills.

An inclusive framework for delivering true early intervention

This should be underpinned by the requirements of the Healthy Child Programme and be based upon theconcept of Progressive Universalism. It would include universal, indicated and targeted interventions, deliveredby different professionals in a variety of settings, including the family home. Set within a developmentalframework (see Appendix 1B below) and would entail:


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1) Getting ready to welcome baby in pregnancy;2) Ensuring optimal bonding during and after delivery;3) Tuning in to the very young baby;4) Supporting baby’s security and autonomy at 8-12 months;5) Setting safe boundaries at 15 months.

Conclusion

Getting the first and centrally important relationship of anyone’s life more or less right is a necessity, not a luxury. This is the most sensible and cost effective time to put in supportive and therapeutic resources. An investment inthe present represents a saving in the future from a reduction in the use of health services, the need for socialcare and in the prison population. The knowledge and skills needed to deliver effective early intervention servicesare well known, and have been successfully applied elsewhere. Based on the principle of incorporating the threedimensions of Progressive Universalism, Building Working Alliances and Infant Maturational Development acomprehensive framework for delivering evidence-based interventions has been outlined.

APPENDIX 1B –

A comprehensive, developmental framework for early intervention

(Shortened version; full version of this paper can be seen on WAVE’s website, www.wavetrust.org)

Getting ready to welcome baby in pregnancy

Universal InterventionsRevision of midwifery input to:

o Engage with all clients (The Family Partnership Model); o Identify vulnerable mothers-to-be in general (PREview);o Identify highly anxious mothers-to-be (Hospital Anxiety and Depression Scale).

This will in practice mean that midwives (as well as health visitors as is current) could use the Family PartnershipModel both to engage with the mother-to-be and also to assess her level of vulnerability and mental healthneeds, referring to health visitor or infant mental health specialist colleagues if appropriate. The health visitor antenatal contact may be used to:

o start to build a relationship with the family (The Family Partnership Model);o build on midwifery assessment to identify presence of risk factors;o provide anticipatory guidance to promote the mental health of the whole family.

Targeted Interventions

o The Department of Health has launched Preparation for Birth and Beyond for people who plan and leadpreparation for parenthood groups and activities. The pack aims to give practitioners the confidence torun groups tailored to the specific needs of those attending, that young mothers and their partners enjoyand that help them adapt to their parenting role.

o A group version of the FNP, initially trialled in two sites, starting in pregnancy and continuing until thebabies are 12 months old. The aim is to reach young women who are not eligible for one-to-one FNP but would benefit from additional support;

o ‘First steps into parenting’ is an evidence-based parenting preparation programme with good outcomes;o ‘Mellow Bumps’ is a group-based intervention derived from the ‘Mellow Babies’ approach. This has been

shown to improve pre-birth mother-baby bonding in high-risk mothers.

Clinically indicated InterventionsIndicated interventions come into play when the parent/s-to-be have been identified as being particularlyvulnerable, complex or at risk through substance abuse, antenatal depression or mental illness, or significant levels of antenatal anxiety, or having or being at risk of developing enduring mental health problems such ashallucinations, delusions, or rapid and unpredictable mood swings. Published NICE guidelines as to treatmentsand interventions should apply. However, in order to be truly preventive, this group should also include pregnant women in dangerous or threatening relationships as well as those disclosing and dismissing past trauma or loss(such as parents who have been in care). The interventions will range from psychotherapeutic work with themother-to-be, with the parents-to-be, to the full range of psychiatric treatment and child protection processes.


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Ensuring optimal bonding during and after delivery

Universal InterventionsFacilitating a ‘secure’ birth through:

o emotional preparation ante-natally;o dealing with expectations of delivery/motherhood/baby;o psychological preparations to cope with pain;o developing a ‘birthing alliance’ through team midwifery, a birthing assistant or doula;o feeling safe and supported through birth venue, birth assistant; and an emergency back-up plan;o saying hello in the baby-friendly way;o kangaroo care, especially if baby is born premature; o ensuring minimal separation after birth;o baby massage;o using a baby sling.

Targeted and indicated interventionsResolving trauma and/or loss consequent on a traumatic delivery through psychotherapeutic work.

Changing the future for infants in intensive careImplementing the Newborn Individualized Developmental Care and Assessment Program (NIDCAP) in hospitals’Neonatal Intensive Care Units.

Tuning in to the very young baby

Universal InterventionsThe purpose of these interventions (which are most likely midwifery-led) is to enable parents to develop a degreeof mindfulness or mind-mindedness by helping them to recognise how ‘smart’ their babies are; demonstratingsuch behaviour as recognition of mother’s voice and smell, baby’s preference for faces, proto-speech, mirroringand provocation as well as baby’s use of self-soothing reflexes. Finally, the intervention should help parents torecognise state changes and the infant’s temperament. The preferred methodology would be for everycommunity midwife to be able to undertake Brazelton’s Neonatal Behavioural Assessment Scale, NBAS, or theshorter Neonatal Baby Observation, NBO, version.

Additional universal interventionBuggy and push chair orientation: There is good evidence that promoting a face-to-face buggy and pushchair orientation can have significant positive benefits on infant development

o Baby massage. The benefits of baby massage are noted above;o Health visiting support through home visiting and ensuring delivery of the universal mental health

promotion elements of the Healthy Child Programme;o Assessment for the possible presence of postnatal depression and other mental illness;o Identifying poor inter-parental relationships and domestic violence.

Health visitor-led Targeted Interventions

o Family Nurse Partnership;o Management of mild to moderate postnatal depression;o Referral and support for inter-parental relationship difficulties.

Other Targeted InterventionsThe central issue at this stage in the infant’s maturational development is to help the parents to developattunement and sensitive responsiveness, to learn to recognise empathically and respond sensitively to theinfant’s communication, thus establishing a mutually rewarding ‘dance’. There is very good evidence that the brief use of ‘Video Feedback’, or ‘Interaction Guidance’, can have a significant positive impact of vulnerable parentsand it is also now commonly used therapeutically in families with more complex problems.

Indicated InterventionsParent-Infant Psychotherapy, including Couple Therapy, Family Therapy, and Perinatal Psychiatric Interventions.

Supporting baby’s security and autonomy at 8-12 months

By 7-8 months, baby’s emerging need for autonomy can at times challenge the parents’ anxieties about allowingthis to happen, and feeding problems and sleep problems manifest. Parents and their babies begin to ‘wrestle’rather than dance. This may occur albeit temporarily in families where the parenting is ‘good enough’ and it is


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resolved as the parents work out the new meaning of the infant’s behaviour. However, in parents with more‘vulnerable’ or ‘complex’ problems, this can quickly escalate and the interventions then become Targeted or Indicated.

Universal InterventionsThe Solihull Approach is already adopted in a number of health visiting services around the country. There isgood evidence as to its effectiveness.

Targeted Interventionso PEEP (Peers Early Education Partnership) is a group-based model grown out of the desire to improve

children’s capacity to learn by helping and supporting parents (Street, 2009);

o Mellow Babies is a development of the Mellow Parenting group-based programme that, although quite‘new’, is developing a good evidence base. It is now applied in a number of localities across the country.

It has been used not only with vulnerable parents but also with families with ‘complex’ problems and ‘at

risk’;

o Circle of Security;o Watch, Wait and Wonder;o Interaction Guidance.

Indicated InterventionsWithin the indicated interventions already discussed i.e. ante-natal, perinatal and infant mental health services, there are three approaches which need specific recognition:

o Circle of Security is a group-based programme using video feedback specifically of the child’s behaviour

in a Strange Situation Attachment Assessment as a basis for the parents’ reflections and discussions;

o Watch, Wait and Wonder is a particular parent-infant psychotherapy approach that requests the parent learns to observe and then follow the child’s lead in play without ‘interference’;

o Parent-Infant Psychotherapy.

Setting safe boundaries at 15 months

Universal InterventionsThe issue at this time is almost invariably about infant behaviour. Sleeping and feeding problems may not havebeen recognised until the infant begins in nursery or day care; behaviour problems have similarly goneunrecognised.

Indicated and Targeted InterventionsIn addition to the peri-natal and infant mental health services already mentioned, these approaches almostinvariably mean using ‘Parenting class’ approaches (not to be confused with more relationship-based parentinggroups) that are now ubiquitous in their use across the country.

The most well-known parenting classes, and with the best evidence as to outcome, are:

The Incredible Years;

Triple P.

References

Appendix 1

WHO. (2001). Mental health: strengthening mental health promotion. [Online] Available at: http://www.allcountries.org/health/mental_health_strengthening_mental_health_promotion.html.

Appendix 1B

Street, A. (2009). Empowering parents through 'Learning together': the PEEP model. In: Barlow, J., Svanberg, P.O. (Eds).Keeping the baby in mind. Hove: Routledge.

http://www.allcountries.org/health/mental_health_strengthening_mental_health_promotion.html


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APPENDIX 2 –

Social and Emotional Assessments

Background

Following the publication of the Healthy Child Programme (Shribman & Billingham 2008), government publichealth policy in England has moved towards a clear recognition of the need to support the parenting of allfamilies, alongside providing additional support to families of infants and young children, experiencing a range or problems that affect their capacity to parent. This move reflects recent evidence showing that early interventioncan optimise the development of all children, and that appropriately targeted intervention along a gradient of need(Marmot 2010) can prevent children living in high risk environments from developing a range of social, emotionaland cognitive problems. A number of recent research and policy reports (Allen and Smith 2008, Barlow et al2008, Field 2010, Munro 2011,Tickell 2011) have underlined the need to assess and intervene as early aspossible, truly developing a primary prevention framework.

In addition to economic and practical issues, the evidence strongly points to the need for appropriate targeting of services, alongside universal provision. This approach is perhaps most succinctly illustrated in the Health Visitor Implementation Plan 2011-15 (Dept. of Health 2011) which outlines the new health visiting service comprisingUniversal Services, through Universal Plus (offering a rapid response in such particular instances of need aspostnatal depression, sleeping problems, weaning or any parental concerns) to Universal Partnership plus whichoffers on-going support from the HV team in partnership with other local services for more complex cases.

The application of the Health Visitor Implementation Plan requires practitioners to have access to practical andevidence-based tools with which to assess the level of need. PREview is one such method of stratifying the levelof risk (see Chimat 2010). This tool was developed following a comprehensive evaluation process of availabledata by the University of York (Hennessy and Green 2008, Hennessy, Green et al 2008, Green 2008, Kiernanand Mensah 2011). However, the report concludes that although the

‘key indicators from the ... analysis showed important associations with the child outcomes and thepropensity score exercise showed that these factors had some power for predicting outcomes ...different set of factors were more or less influential depending on the child outcome under consideration... suggests that it may be more appropriate to take a more holistic approach to understanding how families influence their children’s development and well-being’ (Kiernan and Mensah 2011).

These findings suggest that a reliance on demographic data – although useful from a population point of view –does not necessarily help the individual practitioner in his or her necessary assessment of a family’s need.

This report presents the findings of a comprehensive review of preventive and early intervention services frompregnancy to age two that was aimed at identifying and making recommendations about the most practical andevidence-based methods of assessing social and emotional wellbeing, in order to target services appropriatelyfor this age-group. Together with the reports by the other task groups, it should be regarded as aroadmap/timeline. It is very ambitious and implementation will take some considerable time, as it will needadditional resources and manpower as well as substantial training, but then any journey begins with a first step.

The purpose of this appendix is:

1. To identify evidence-based social and emotional assessments (including assessment of emotionalregulation) that could be incorporated within the Healthy Child Programme. The focus is exclusively onsocial and emotional well-being, and does not therefore include tools for the assessment of neuro-developmental disorders for example.

2. To address the training implications of the implementation of the identified tools.

The underlying principles, which have guided the appendix, are as follows:

1. The purpose with all assessments of a child’s social and emotional wellbeing should be to establish thelevel of social and emotional functioning of the infant in addition to the sensitivity/responsiveness ofrelevant carers in order to guide the family and the practitioner towards the most appropriate support and intervention for the family within the context of a gradient of need.

2. Assessment tools should be practical as well as valid and reliable, based not only on sound researchand evaluation but also on a high likelihood of being implementable as part of a busy practice.

3. All assessment tools need therefore to make sense to parents and carers, and to be seen as supportiverather than judgemental; this requires that such tools be implemented as part of a promotional andpartnership model of working.

4. Measures and methods must be usable across the whole spectrum of ability, including socialdisadvantage, disability, culture and language.


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5. Finally, training in any proposed assessments must be easily accessible and not prohibitively time-consuming or expensive.

Current practice

Screening for PND

NICE Guidelines

Pregnancy booking appointment:i. Assessment of social and emotional risk and resilience factors in mother, father and wider social

context;ii. Specific questions about:

o past or present severe mental illness including schizophrenia, bipolar disorder, psychosis in thepostnatal period and severe depression;

o previous treatment by a psychiatrist/specialist mental health team including inpatient care;o family history of perinatal mental illness, as per NICE guidance.

At Initial Health visitor appointmentsAt a woman’s first contact with primary care, at her booking visit and postnatally [usually at 4 to 6 weeks and 3 to4 months (for families of higher needs)], healthcare professionals (including midwives, obstetricians, healthvisitors and GPs) should ask two questions (the Whooley questions) to identify possible depression.

o During the past month, have you often been bothered by feeling down, depressed or hopeless?o During the past month, have you often been bothered by having little interest or pleasure in doing

things?

A third question should be considered if the woman answers ‘yes’ to either of the initial questions.o Is this something you feel you need or want help with? (NICE guidance)

10-14 days postnatallyi. Assessment of maternal mental health (as above);ii. At present the HCP also advises an assessment of parent-infant interaction and recommends using the

Neonatal Behavioural Assessment Scale (NBAS) or the Nursing Child Assessment Satellite Training(NCAST),

6-8 weeks – as above

3-4 months – as above

7-9 months – as above plus assessment of infant’s social and emotional development

2-2.5 years – assessment of toddler’s social and emotional development

The child in need assessment framework and locally developed assessments are probably the most commonused currently (See http://www.archive.official-documents.co.uk/document/doh/facn/fw-02.htm)

Stratification of services

As noted above, PREview may well be of great help on a population level but for the individual practitioner it hasnot added anything not already known. The assessments noted below are proposed as useful tools to enable theindividual practitioner to make a judgement as to which level of services will best match the identified level of need.

Note: Before any of these assessments are included and used in a local service, it is imperative that UniversalPlus and Universal Partnership Plus services (including antenatal, perinatal and infant mental health services) are available in the locality. There is nothing more morale-sapping for a practitioner than to identify a clear needwithout an available service.

A note about child protection issuesMost serious child abuse is essentially unpredictable – even if the ‘whole picture’ had been known, it would not always have been possible to anticipate serious abuse for most of the children at the centre of serious casereviews. This emphasises the risk of providing a very selective service to families who are deemed vulnerable’(Rose, 1993). A robust universal service is essential for safeguarding and child protection.

The possible danger with targeting services at only those of high risk will be that vast swathes of families withsubstantial but not life-threatening health and social problems will be ‘invisible’. Rose (1993), states that no one


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screening instrument can be sufficiently precise to identify accurately those most likely to suffer problems. Seealso Browne (2002) and Barlow and Stewart-Brown (2003).

The biennial analysis of serious case reviews 2003-2005 (Brandon et al, 2008), support Rose’s (1993) andBarlow and Stewart Brown’s (2003) argument that the bulk of problems in society arise in the many who are not necessarily high risk rather than the few who are high risk. The reason for this is that there are a very largenumber who are not at especially high risk.

Child abuse, domestic abuse and depression are common problems that health visitors deal with regularly. Todetect and prevent child maltreatment, a population level approach is essential (Barlow and Stewart Brown, 2003). For this to be effective, it cannot be emphasised enough that practitioners need time to develop trusting relationships with families as part of their holistic assessments. In addition, by using, or having access to, anassessment and partnership model as outlined below where, over time, the assessments move from a focus onthe mother/parents to the infant to the parent-infant relationship, signs of risk in the development of the child willbe identified early and additional help and support provided, reducing the likelihood of adverse outcomes.

Proposed frequency of assessmentsThese more or less follow the NICE guidelines with some modifications.

Early pregnancy at the pregnancy booking-in appointment. Following the NICE guidelines to assess ‘socialand emotional risk and resilience factors in mother, father and wider social network’ the purpose of thisuniversal assessment is to evaluate any significant risk factors in the mother’s life. These are such risks asmental ill health, domestic violence, drug and alcohol abuse as well as such risks to the foetus as substanceabuse, including smoking as well as significant levels of antenatal anxiety or depression. Resilience factorsmay include evidence of coping, supportive family relationships, especially with partner and own mother, andother relationship support.

Health visitor universal antenatal visit around 28 weeks’ gestation

1st Promotional Interview by the health visitor using the Promotional Guide and in the context of apartnership approach to working. This is the first of two such promotional interviews that are aimed at a) promoting the wellbeing of all women; b) identifying women/families in need of Universal Plus services or Universal Partnership Plus that will involve referral to other services. The promotional interview providespractitioners with the opportunity to get to know the woman and her partner before the arrival of the infant, tosupport aspects of pregnancy that are going well, and to explore areas about which the woman/couple mayhave concerns. Although the promotional guide is comprehensive, the interview is patient-led, and aimed at providing women and their partners with the opportunity to think about the pregnancy, their developingrelationship with the foetus, and the impact of the pregnancy on their relationship. The Promotional Guide isaimed at helping practitioners to identify medium level need (e.g. ambivalence feelings about the pregnancy; depression and anxiety) that can be met using Universal Plus services, or high level need that requiresUniversal Partnership Plus and referral to other services in accordance with the care pathways in place, e.g. serious mental health problems; substance dependency; and domestic violence (Davis 2009). Additionally, the health visitor can utilise a more formal assessment with one or more of the tools mentioned below.

10-14 days 2nd Promotional Interview: This is the scheduled universal visit when the health visitor willconduct the second promotional interview using the Promotional Guides in the context of a partnershipmodel of working. The visit therefore provides another opportunity a) to promote wellbeing for allmothers/families; b) to assess the level of risk and resilience of the mother, the baby and the family so that the health visitor and parents can together make a decision as to what level of service provision should beappropriate. It also offers the first opportunity to assess mother’s perception of her real baby (as opposed tothe views of the imagined baby that were developed during pregnancy), and the parent’s ability for attunement and for reflective functioning, both of which are predictive of the future relationship with the baby. It therefore provides an opportunity for practitioners to introduce the social baby; the concepts of ‘readingand understanding baby cues’, baby states etc.

14- 21 days (postnatally). This would be the ideal time to undertake an evaluation of the baby’s reactivity

and habituation to external stimuli, most often thought of as the infant’s ‘temperament’. By undertaking aNeonatal Behavioural Assessment (NBAS) or a Neonatal Behavioural Observation (NBO) (see below) in thepresence of the parents, the health practitioner will not only establish the baby’s reactivity but also increasethe parents’ empathic understanding of their baby’s reactions. This assessment should be focused on morevulnerable parents, or parents who have complex problems, and it is not envisaged as a universal service. Whether this assessment is undertaken by the community midwife or the health visitor may be a localdecision depending on available resources.

6-8 weeks. In line with NICE guidance, this is a second opportunity to assess risk and resilience which maynot have been completed earlier.


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At 3-4 months the parent-infant interaction will have developed its own rhythm and patterns and the purposeof the assessment at this point is to evaluate the quality of the parent-infant interaction in terms of parentalsensitive responsiveness as well as parental perceptions or attributions, unless this has already beenassessed. In line with the Healthy Child Programme, this should be a formal, universal assessment. This is acrucial stage on the pathway to secure, or insecure, attachment and without assessing every mother-infant dyad, attachment difficulties would be missed at this crucial early stage..

The 8-9 months developmental review remains as at present. Regrettably, this is a little too early toundertake any evaluation of the baby’s attachment behaviour which does not become clearly established until12-15 months. Therefore, it is proposed that this additional assessment opportunity be added to the HCP at12-15 months.

The purpose of the assessment at 12-15 months should be to assess the infant’s attachment behaviour. At this age the infant will have developed clear attachment behaviours as well as strategies to emotionallyregulate. This offers the first opportunity to assess for risk and resilience in the infant and is also earlyenough for targeted or indicated interventions to help change a possible pathway towards insecureattachment and/or pathology. The assessment should be offered only to parents in the Universal Plus or Universal Partnership Programme.

22- 24 months (replacing the 2.5 year review). As additional support is soon to become available tovulnerable children at age 2, it is logical to move the 2.5 years review to an earlier time. Any significant emotional and/or social problems for the baby will now be apparent and should emerge in areview/discussion between parents and practitioners. These would be such issues as sleep, eating orgeneral behaviour problems, and the practitioner can choose to rely on his or her professional judgementsas to the severity of these problems or choose to use a more formal assessment. Of particular importance at this time is the assessment of language development.

Recommended assessment methods

This section comprises a list of recommended assessments and evaluation tools. Some are for universal use, others only in the assessment of vulnerable or complex cases. It is important to note that across the time periodfrom early pregnancy to age 2 these assessments are complementary, each one adding further information to thewhole picture of offering the right level of help and support at the right level of need. (Baggett et al 2007, Carter 2002, Denham et al 2009, Ringwalt 2008)

Pregnancy booking-in appointmentAssessing and enquiring about intimate and personal details is a highly skilled activity, the core of which is torapidly establish a trusting relationship and a good ‘working alliance’. In order to facilitate this process it isstrongly recommended that all community midwives and health visitors are trained in ‘The Family PartnershipModel and promotional interviewing (Davis 2009). These health professionals will then be better placed to build atruthful picture of the risks and resiliencies of the family. The NICE guidelines are unfortunately very sparse inrecognising social or emotional risk (other than substantial psychiatric disorder). On the other hand, the HCP mandates: ‘A full health and social care assessment of needs, risks and choices by 12 weeks of pregnancy by amidwife or maternity healthcare professional’ identifying the following risk factors:

o young parenthood, which is linked to poor socio-economic and educational circumstances; o educational problems – parents with few or no qualifications, non-attendance or learning difficulties; o parents who are not in education, employment or training; o families who are living in poverty; o families who are living in unsatisfactory accommodation; o parents with mental health problems; o unstable partner relationships;o intimate partner abuse; o parents with a history of anti-social or offending behaviour; o families with low social capital;o ambivalence about becoming a parent;o stress in pregnancy; o low self-esteem or low self-reliance; ando a history of abuse, mental illness or alcoholism in the mother’s own family.

There is evidence that the impact of these risk factors is not straightforward. Thus a woman may be able to copewith one or two risk factors (particularly if she is well supported by partner or family) but ‘collapses’ if another riskis added.

Following booking-in the midwives should notify all health visitors of pregnancy women to enable them to conductan antenatal promotional interview at 28 weeks.


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Antenatal Promotional Interview – 28 weeksThe core purpose of this assessment is a) to promote wellbeing for all pregnancy women/couples; b) to identifyvulnerable women or women with complex psychological problems, and to distinguish between women in need of Universal Plus level services and Universal Partnership Plus. The latter will have been identified via the APG ashaving one of a number of problems that require referral to additional services (e.g. serious mental healthproblems; substance dependency; domestic violence.

The antenatal promotional interview involves the use of the Antenatal Promotional Guide (APG) which isconducted using the Partnership Model of working (Davis 2009), and covers the key areas associated withcompromised foetal development, and also with a compromised relationship with the infant. For example, evidence suggests antenatal depression and antenatal anxiety (O’Connor et al 2002) can have significantlydetrimental impact on the foetus’ neurological development (Matthey 2004), and can also impact on the long-termdevelopment of the infant and child. The APG asks women about their experience of both anxiety and depression(the latter based on the 3 Whooley questions). Where concerns are identified, the practitioner may then wish toutilise a standardised tool to assess the level of anxiety or depression. This could be done using the EPDS or theHADS. Another area that is a focus of the APG is the mother’s attachment to the foetus. Where the health visitor hasidentified problems and wishes to explore these further using a standardised tool, the Antenatal Attachment Questionnaire (Condon 1993) can be used.

10-14 days This is the scheduled universal visit when the health visitor is first likely to meet the mother and infant. In order tomake the best use of this opportunity to engage the family, the health visitor needs to be ‘sensitively responsive’to them. He or she will also be a potential ‘change agent’ for the family, engaging them in Universal Plus or Universal Partnership Plus targeted interventions. Thus, it is recommended that (following the Family NursePartnership practice) all health visitors train in the use of Motivational Interviewing.

This visit provides another opportunity to assess the level of risk and resilience of the mother, the baby and thefamily so that the health visitor together with the family can make a decision as to what level of service provisionis appropriate. This is an opportunity for the health visitor to assess whether the mother may be showing signs of Post-Traumatic Stress Disorder and a simple screening tool to identify PTSD can be used to focus practitioner assessment – Primary CARE PTSD Screen. (Prins et al 2003). It is recommended that he or she re-visits theareas of risk outlined above during the early pregnancy and discusses these areas of vulnerability with themother and (if appropriate) her partner.

The visit offers the first opportunity to assess mother’s perception of her ‘real’ baby. Ten to fourteen days istoo early for mother to have formed any very clear attributions of baby but again the practitioner needs to besensitive to highly negative, hostile or distorted comments the parents may voice about the baby.

Finally the visit gives the health visitor an opportunity to introduce the concepts of ‘reading and understanding baby cues’. The practitioner might also use the Brazelton Neonatal Behavioural Scale or the NeonatalBehavioural Observation (see below) with the parents to introduce them to the social baby, and to help them tobegin to understand their baby’s behaviour characteristics in terms of strengths, and areas that may needsupport. For example, where babies are ‘difficult to settle’ the practitioner might help.

14 - 21 days postnatally As noted above, this would be the ideal time to undertake the short form of theNeonatal Behavioural Assessment Scale (NBAS), called the Newborn Behavioural Observation, in the presenceof the parents (Brazelton and Nugent 1995, Nugent and Brazelton 2000) (See also www.brazelton.co.uk). Not only will this establish major temperamental characteristics of the baby, it will also offer an opportunity for theparents to learn about their baby’s way of adapting, which will increase their empathy. Ideally it should be offeredat a Universal level, but this might only be possible over time.

This assessment could be offered by the community midwife. Alternatively, as there is currently a shortage of midwifes, it could instead be offered by health visitors. There are clear advantages to using this model as theassessment then would also be a valuable addition to the necessary development of trust and co-operationbetween the health visitor and the family. Which professional group actually undertakes the assessment may befor discussion between midwifery and health visiting at the local level.

6-8 weeksSecond Postnatal Promotional InterviewThis is the second of the two Promotional Interviews using the Postnatal Promotional Guide (PPG) in the context of partnership working. As with the antenatal interview, the aim is to a) promote the wellbeing of all women; b) identify which women have additional needs in terms of the provision of Universal Plus or Universal PartnershipPlus. In terms of promoting the wellbeing of all women, the Postnatal Promotional Interview provides the context within which to assess the parent-infant interaction, including the mother’s developing perceptions about the


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baby and the presence of highly negative, hostile or distorted comments about the baby; introduce the conceptsof ‘reading and understanding baby cues’; and baby states. The Postnatal Promotional Guide includesquestions about the mother’s mental health, including an assessment of postnatal depression (using the 3Whooley questions).

In terms of families identified as having additional needs, health visitors will be a potential ‘change agent’ for families identified as needing Universal Plus and Universal Partnership Plus. The Family Partnership Model of Working provides practitioners with the necessary skills to work with families to achieve change using acognitively based partnership model. Motivational Interviewing (i.e. as distinct from Promotional Interviewingabove) is another evidence-based technique that can be used by primary care practitioners to help familiesachieve change and is central to Family Nurse practice.

Gloucestershire has developed a checklist (Appendix 2C) which may guide discussions at this time. Using achecklist of this nature is a training issue as there is evidence that the use of this type of checklist candisempower parents (Mitcheson & Cowley 2003). It also needs to be recognised that checklist and tools can lullpractitioners into a false sense of security and can produce false negatives and miss children at risk.

The Hospital Anxiety and Depression Scale can also be used postnatally to establish early significant levels ofpsychological distress or anxiety very likely to impact the relationship with the infant. There are a number ofscales available for this purpose and practitioners may want instead to explore the Kessler-10 previouslyrecommended by CORE.

o Kessler-10 is a 10 item self-administered questionnaire assessing psychological distress. It has beenused in a series of large studies in the US as well as Australia. Information about the scale and scoringis available from http://www.hcp.med.harvard.edu/ncs/k6_scales.php

There are numerous brief questionnaires to assess formally mother’s perceptions of the infant. These are allcompleted by the parent and later scored by the practitioner. They are brief, easily accessible, practical, withsignificant predictive power. It is recommended that one or two of the following tools are used:

o The Ages and Stages Questionnaire – 2 months (Briggs et al 2012) see alsohttp://www2.fiu.edu/~aip/documents/AgesandStages.pdf. The ASQ has in fact a range of questionnairesover the child’s development which can be used to track changes and measure improvement.

o Maternal Attitude Scale (Bor et al 2003). This is a 6 item scale where maternal negative attitudetowards the infant is an independent predictor of child behaviour problems (boys’ externalisingbehaviour and girls’ internalising behaviour) at age five (see Appendix 2D).

o The Post-partum Bonding Questionnaire (Brockington et al 2001, 2006) is a 25 item scalewhich may still need some further validation but is useful with information not only about mother’sperception but also other risk factors.

o The Maternal Object Relations Short Form (MORS-SF) (Milford and Oates 2009) has alreadybeen validated in a project in North Somerset and again gives information about mother’s attributionsand perceptions of baby (available from John Oates).

3-4 months The most salient dimension of the early years is the parent-infant relationship. It has been very clearlyestablished as being the best predictor of the child’s future wellbeing and it is thus crucial to assess this coreaspect. This assessment should be Universal and it is recommended that one of the following interactionalassessments is used to assess the parent-infant relationship.

o Keys to Interactive Parenting (Comfort et al 2006, 2011) KIPS assesses 12 parenting behaviours in a20 minute observation followed by some 10 minutes of scoring. It has published reliability and validitydata and training can be accessed via the Internet. (http://www.comfortconsults.com/kips.htm)

o Parent-Infant Interaction Observation Screen. The PIIOS is a 13 item scale used to guide theassessment and evaluation of a video of a brief parent-infant interaction. The scale is highly correlatedwith the sensitivity scale of the CARE-index as an external validation, and its internal reliability is alsoexcellent. It is in the final stages of development by Svanberg and Barlow at the University of Warwickand should become available through an Internet accessible training in 2013.

o Emotional Availability Scales (Biringen, 2000) is a method of assessing dyadic interaction for theemotional availability of the parent to child and child to the parent. It is a global measure of overallinteractional style in each partner and requires clinical judgement and an awareness of contextualfactors. There is extensive research to show it is highly associated with the infant’s later attachment behaviour. Two versions of the four EA scales are available for different ages of the child, the salient one for the purpose of this review being ‘The Infancy to Early Childhood Version’ (0 to 4 years) Therecommended method for coding the EA scales is to video-record and later analyse at least 20 minutesof interaction, although it has been used for shorter time periods. Substantial US-based training isrequired to reach reliability on the scales. Training can be done via distance learning DVDs and

http://www2.fiu.edu/~aip/documents/AgesandStages.pdf

http://www.comfortconsults.com/kips.htm


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consultation and/or follow-up workshops. Given the extensive training, this approach may be most useful in the assessment of Universal Partnership Plus families. It is not recommended for Universaluse. Further information is available at http://www.emotionalavailability.com/ea-distance-training-and-certification.

o The CARE-Index (Crittenden 1997-2004) is based on a brief (3-4 minutes of ‘playing and talking’)

video-clip of caregiver and infant or toddler (range 2 months to 4 years). It is currently used in a number of infant-mental health services across the country both for initial assessment and for outcomesevaluation. A handful of people in England are trained to the level of accredited teachers. The drawbackwith the tool is that it demands an extensive training and that reliability is difficult to achieve.Notwithstanding this, it can be a very important tool, particularly in child protection evaluations and it isthus recommended for this purpose. Further information is available at http://www.patcrittenden.com/

o The Nursing Child Assessment Satellite Training (NCAST) (Barnard 1997) was developed in Seattlein the early 1970s as one of the first parent-infant interaction tools focusing particularly on feeding andteaching behaviour. Recommended by the HCP, it was initially used by the Family Nurse Partnership inEngland but was later substituted by their ‘in house’ tool. It is currently used extensively in Leeds(Mishenko et al 2004). (See also http://www.browninghouse.org.uk/news/article.php?article_id=28)

In addition to using an interactional assessment it is recommended that the health visitor again uses the followingbrief questionnaires for more vulnerable families.

o The Ages and Stages Questionnaire – Social and Emotional (SE). This version of the ASQ (best usedat 6 months) is a brief screening version identifying social and emotional issues for the baby.

In addition, the following tool was specifically constructed to assess risk for abusive behaviour and is thusrecommended when there are child protection concerns as part of a social services assessment.

o The Adult-Adolescent Parenting Inventory (AAPI-2) (Bavolek 1989) is a 40-item questionnaire usedto assess parenting attitudes and child-rearing practices of adolescents and adults. The purpose of theinventory is to determine the degree to which respondents agree or disagree with parenting behavioursand attitudes known to contribute to child abuse and neglect. Responses provide a standard for risk infive parenting constructs known to contribute to the maltreatment of children: (1) inappropriate parentalexpectations, (2) inability to demonstrate empathy towards children’s needs, (3) strong belief in the useof corporal punishment, (4) reversing parent-child family roles, and (5) oppressing children’s power andindependence. Training is US-based unfortunately, and it is not known whether there are services inEngland already using the tool. (See also http://www.nurturingparenting.com/)

There is of course an array of published tools to, for example, assess parents’ psychological or psychiatricproblems, couple functioning etc., but all of these will be part of specialist perinatal and infant mental healthservices as well as social services.

12-15 monthsIn an ideal world the technical facilities and trained practitioners would be available so that Ainsworth’s StrangeSituation could be undertaken. The Strange Situation (particularly when analysed using Crittenden’s Dynamic

Maturational Model) is the absolute gold standard when it comes to assessing an infant’s attachment behaviour. However, training is very difficult to access and the technical requirements are costly. However, particularly inchild protection assessments when the issue is about the removal of the child from the family, the methodology isunrivalled. (See www.pmcrittenden.com)

There are numerous variants on the Strange Situation in the research literature as well as such other proceduresas The Crowell Procedure (see http://www.infantinstitute.com/Crowell2005.pdf) and the Attachment Q sort(ASQ) (Waters and Deane 1985) but the requirements for undertaking these procedures are such that theybecome impractical for routine use. It may have a place, however, when there are concerns about the need toremove the infant.

Instead it is recommended that the infant’s social and emotional wellbeing at this age is assessed using the Brief Infant and Toddler Social and Emotional Assessment (Briggs Gowan et al 2004). The BITSEA is a 36 itemparent-completed form used when the infant has reached 12 months. It is easy to administer and analysealthough somewhat expensive as it is copyrighted. However, it has good predictive value (Briggs Gowan et al2008) and in lieu of observational data it is practical and easily accessible (Briggs Gowan et al 2012).

Additionally the Ages and Stages Questionnaire-12 months can be used.

22- 24 months (replacing the 2.5 year review).The Achenbach System of Empirically Based Assessment – Preschool Module (ASEBA) (seehttp://www.assess.nelson.com/aseba/aseba.html) is used to assess adaptive and maladaptive functioning usinga set of rating forms and profiles. The ‘Child Behaviour Checklist (CBCL/1.5-5)’ is a parent-completed 99 item

http://www.emotionalavailability.com/ea-distance-training-and-certification

http://www.emotionalavailability.com/ea-distance-training-and-certification

http://www.patcrittenden.com/

http://www.browninghouse.org.uk/news/article.php?article_id=28

http://www.nurturingparenting.com/

http://www.pmcrittenden.com/

http://www.infantinstitute.com/Crowell2005.pdf

http://www.assess.nelson.com/aseba/aseba.html


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questionnaire already in common use in England, which also includes the Language Development Survey (LDS). It is recommended for use at Universal Plus and Partnership Plus service levels.

Toddler Attachment Sort-45 (TAS-45). The US government-funded ‘Early Childhood Longitudinal Study’(ECLS) was designed to provide policy makers, researchers, child care providers, teachers and parents withdetailed information about children's early life experiences. The study followed up a nationally representativesample of approximately 14,000 children born in the U.S. in 2001. (see http://nces.ed.gov/ecls/birth.asp). It wasimportant for this study to include an assessment of attachment (Spieker 2003) and in order to develop a brief and practical method the project linked up with John Kirkland in New Zealand. He had previously developed a‘spatial’ model of the Attachment Q-sort (Bimler and Kirkland 2002, Kirkland and Bimler 2004) and the issue waswhether this methodology could be used in a shorter, more practical form. The TAS-45 is the result (Condon andSpieker 2008, Spieker et al 2011, Andreassen and West 2007). Following a 90-minute parent-infant observation, the practitioner undertakes a comparative Q-sort, which takes some 10-15 minutes to complete. Using a lap-top,the practitioner sorts the 45 descriptive items into 4 piles (plus one for ‘unsure’) which will provide reliableinformation about the child’s attachment behaviour and also specifically identify those children most at risk of disorganised attachment. It should be possible to replicate the training for the Early Childhood Longitudinal Studyin this country without too much difficulty and the burden of introducing the assessment as part of the 24 monthreview should be minimal, i.e. an extra 10-15 minutes of completing the Q-sort ‘back at base’. For a summary of all recommended assessments see below.

Additional tools, measures or assessment procedures

The Atypical Maternal Behavior Instrument for Assessment and Classification (AMBIANCE); (Lyons-Ruthet al 1999) was developed specifically to identify maternal behaviour which is highly associated with‘Disorganised attachment’. It is a video-based procedure, still more of a research instrument and the US-basedtraining is very difficult to access (see also http://www.challiance.org/Academics/AMBIANCETraining.aspx).

The Alarm Distress Scale (Guedeney and Fermanian 2001) is another recent video-based screeningprocedure. Developed in France, it has good reliability and validity (Lopes et al 2008) and has been usedelsewhere in Europe (Puura, et al 2007, 2010), although evidence is not yet available as to its predictive value inlarge samples.

The Child Development Inventories – the Infant Developmental Inventory is a 300 item parent-completedquestionnaire and screen for language, motor, cognitive, pre-academic, social, self-help, behaviour and healthproblems. Although the original standardisation was done on a homogenous sample, subsequent validity workhas demonstrated that the instrument is effective with minorities and with lower-income families (Ireton 1997)(see also http://www.childdevrev.com/page15/page17/cdi.html)

The Functional Emotional Assessment Scale was developed as a criterion-referenced instrument for childrenranging in age from 7 months through 4 years of age. It was designed specifically to measure emotionalfunctioning in children with constitutional- and maturation-based problems (e.g. regulatory disorders), childrenwith interactional problems leading to a variety of such symptoms as anxiety, impulsivity, depression, etc., andchildren with pervasive developmental difficulties, and would thus be most useful in the pediatric clinic (seehttp://www.icdl.com/dirFloortime/research/FunctionalEmotionalAssessmentScale.shtml)

Family Star The assessment is part of a large family of similar procedures focusing on outcomes evaluation.Theoretically these evaluations are based on ‘The Cycle of Change’ (Prochaska and DiClemente 1982). Thereseem to be no details as to reliability or validity of these instruments.

The famous Stanford Marshmallow Test (Mischel et al 1972) evaluated 4-year-olds capacity for delayedgratification and emotional regulation and proved to be highly predictive. However, the test would not beappropriate for two-year-olds.

Training implicationsIt has already been noted that the skill of rapidly establishing and maintaining a trustworthy relationship isabsolutely central to effective assessment as well as intervention. Thus it is recommended that:

1. All community midwives are trained in the Family Partnership Model and that they subsequently haveaccess to good clinical consultation opportunities from an antenatal, perinatal and infant mental healthteam.

2. All health visitors are trained in the Family Partnership Model as well as in the Motivational InterviewingModel and again that they have access to good clinical supervision from their local antenatal, perinataland infant mental health team.

In relation to training in the use of specific approaches it is recommended that:

http://nces.ed.gov/ecls/birth.asp

http://www.challiance.org/Academics/AMBIANCETraining.aspx

http://www.childdevrev.com/page15/page17/cdi.html

http://www.icdl.com/dirFloortime/research/FunctionalEmotionalAssessmentScale.shtml


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3. Midwives are trained in the administration and scoring of the Hospital Anxiety and Depression Scale aswell as sensitively being able to enquire about risk and resilience aspects of the family including

a. Mother’s perceived relationship with the family and partner. b. Mother’s perception and attributions of the foetus.c. Resilience factors.

4. Community midwives or health visitors are trained to undertake the Newborn Behavioural Observation.All health visitors need to be competent and feel confident in order to assess effectively risk andresilience.

5. Health visitors are trained in the administration and scoring of the Hospital Anxiety and DepressionScale as well as sensitively being able to enquire about risk and resilience aspects of the familyincluding

a. Mother’s perceived relationship with the family and partner. b. Mother’s perception and attributions of the baby.c. Resilience factors.

6. He or she are trained to use at least one of the following questionnairesa. The Ages and Stages Questionnaire – 2 monthsb. Maternal Attitude Scalec. The Post-partum Bonding Questionnaired. The Maternal Object Relations Short Form (MORS-SF).

Being able to analyse and understand parent-infant interaction is one of the most important skills a health visitor should have.

7. At a universal level it is recommended that all health visitors are trained in one of the appropriateprocedures such as

a. Keys to Interactive Parentingb. Parent-Infant Interaction Observation Screen

8. In addition to using an interactional assessment, it is recommended that the health visitor is trained toadminister the following brief questionnaires for more vulnerable families.

a. The Ages and Stages Questionnaire – 4 monthsb. The Brief Infant and Toddler Social and Emotional Assessmentc. The Child Behaviour Checklist – 1.5 years

9. Finally, to be able to establish specifically the attachment behaviour of the two-year-old, it isrecommended that the health visitor is trained to observe and analyse the Toddler Attachment Q-sort-45.

10. In addition, it is recommended that when assessing a family of one to two year olds when there is a childprotection concern, the Adult-Adolescent Parenting Inventory (AAPI-2), the CARE-Index or the(Dynamic Maturational model) Strange Situation is included in the standard assessment framework

. It should be recognised that training the early years’ work force in this manner is a very substantial undertaking. Itis noted that training providers will not as yet have the capacity to offer the recommended training to thenecessary scale and it will take time to ‘scale up’. To be realistic it may be a 6-10 year process before all thespecific skills are available across the country. However, no training in any assessment skill should be offeredunless the practitioner is trained in promotional interviewing or motivational interviewing. Using an assessment tool insensitively is very likely to do more harm than good and should be resisted (e.g Mitcheson and Cowleyreference).

Implications to practice following implementationThe quite outstanding levels of engagement and retainment demonstrated by the Family Nurse Partnership canprobably in part be related to the fact that the Family Nurse established a ‘working alliance’ with the family duringpregnancy. To build on this knowledge it is thus recommended that once risk has been established by themidwife’s assessment at 12 weeks, a referral is made to the health visiting service for vulnerable families and for families with complex problems. This will enable the health visitor to establish one or two promotional visits tobuild a relationship with the family before the baby is born. A practice protocol to establish these changes needsto be constructed for both midwives and health visitors.

Implications to the service following implementationAs noted, the training and practice implications of these recommendations are very substantial. However, theyshould not be unmanageable with the appropriate resources in place. Thus it is recommended that government:

1. Resolves all contractual and licensing issues with copyright holders and buys or leases copyright centrally. This should reduce the costs considerably.

2. Commissions a number of translations so that all materials, measures or tools are validated for the usewith all cultures and available in all major languages.


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3. Commissions the build of a comprehensive web-site where practitioners can access all material andwhere automated analyses can be carried out.

4. Pilots the use of laptops or tablets where all material is available and analyses can be carried out at theclick of a mouse.

Additional research recommendations

Whilst reviewing the field, it has become apparent that there are a number of research approaches which couldbecome very useful in practice although they are not yet developed for routine use in universal services.

One such approach is the Still Face Paradigm (Tronick and Cohn 1989) which has been shown to predict later attachment behaviour (Cohn and Campbell 1991). Building on the work by Fuertes et al (2006) it should bepossible to develop a simple way of coding the Still Face procedure and establish its association with attachment behaviour.

It has now become relatively simple to establish physiological signs of stress by assaying cortisol levels from asimple mouth swap (Gunnar and White 2001, Gunnar 1992) and high levels have been associated withdisorganised attachment behaviour (Hertsgaard et al 1995). Again, to establish these associations in a largecohort could potentially be very useful.

There is additionally a dire need to resolve a number of the outstanding issues in the field currently competingover theoretical approaches, methodological issues and interventions. The government would be well advised toscope this area and fund some comprehensive, large scale longitudinal research specifically into infants’ and children’s attachment behaviour and social and emotional well-being over time.

Finally, desperately needed is research into service delivery and the use of skill mix so there is clarity as to whoshould deliver these interventions, often to very vulnerable and hard-to-engage families. Whilst the evidence isthat this needs very skilled staff (Olds, Henderson et al 1999, Olds 2002), in recent years we have seenincreasing skill mix in health visitor and other professionally led teams and the delegation of many interventionsto staff with little professional training through children’s centres. If this research were done, commissionerswould be better informed to allocate.


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A summary of recommended assessments (additional to current practice)

Universal Universal Plus PartnershipPlus

ChildProtection

Ante-natal booking in12 weeks

Comprehensive risk assessment as outlined in HCP

Antenatal Attachment Questionnaire

Ditto

Ante-natal 28 weeks

Antenatal promotional interview risk assessment

10-14 days Promotional interview and risk assessment

Primary CarePTSD screen

Ditto

14- 21 days Neonatal Behavioural Observation

Ditto

6- 8 weeks Promotional interview HADS or Kessler-10Ages and Stages- 2 months

Maternal Attitude Scale orPost- Partum BondingQuestionnaire orThe Maternal Object RelationsShort Form

Ditto

3-4 months Keys to InteractiveParenting or Parent-Infant Interaction Observation Screen

Ditto Emotional AvailabilityScales,The CARE-IndexThe Adult-Adolescent ParentingInventory (AAPI-2)

8-9 months

12-15 months BITSEAAges and Stages-12

Ditto As above plusThe DMM StrangeSituation

22-24 months LanguagedevelopmentChild Behaviour ChecklistToddlerAttachment Sort – 45


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Appendix 2B

The anxiety and depression scale

Your Name: _____________________________ Date: _________________________

This questionnaire is designed to help us to know how you feel. Ignore the numbers printed on the left of the questionnaire. Read each item and underline the reply which comes closest to how you have been feeling in the past week.

Don’t take too long over your replies; your immediate reaction to each item will probably be

more accurate than a long thought-out response.

I feel tense or ‘wound up’:3 Most of the time2 A lot of the time1 From time to time, occasionally0 Not at all

I still enjoy the things I used to enjoy:0 Definitely as much1 Not quite so much2 Onl a little3 Hardly at all

I get a sort of frightened feeling as if something awful is about to happen:3 Very definitely and quite badly2 Yes, but not too badly1 A little, but it doesn’t worry me0 Not at all

I can laugh and see the funny side of things:0 As much as I alwa s could1 Not quite so much now2 Definitely not so much now3 Not at all

Worrying thoughts go through my mind:3 A great deal of the time2 A lot of the time1 From time to time, but not too often0 Only occasionally

I feel cheerful:3 Not at all2 Not often1 Sometimes0 Most of the time

I can sit at ease and feel relaxed:0 Definitely1 Usually2 Not often3 Not at all


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I feel as if I am slowed down:3 Nearl all the time2 Very often1 Sometimes0 Not at all

I get a sort of frightened feeling like ‘butterflies’ in the stomach:0 Not at all1 Occasionally2 Quite often3 Very often

I have lost interest in my appearance:3 Definitely2 I don’t take as much care as I should1 I may not take quite as much care0 I take just as much care as ever

I feel restless as if I have to be on the move:3 Very much indeed2 Quite a lot1 Not very much0 Not at all

I look forward with enjoyment to things:0 As much as ever I did1 Rather less than I used to2 Definitely less than I used to3 Hardly at all

I get sudden feelings of panic:3 Very often indeed2 Quite often1 Not very often0 Not at all

I can enjoy a good book or radio or TV programme:0 Often1 Sometimes2 Not often3 Very seldom

Now check that you have answered all the questions

D: A:


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APPENDIX 2C

Risk factors

Check list for early intervention: Risk factors that stress the caregiving relationshipResearch indicates a number of risk factors that impose a strain on the baby-parent relationship. The presence of four to six moderate risk factors is significant although some combinations of a lesser number merit attention invulnerable families. However, there are certain serious conditions that on their own may call for intervention.

1. Biological Vulnerability in the Infant:Low birth weight / prematurity ……Failure to thrive / feeding difficulties / malnutrition ……Developmental delays ……Exposure to harmful substances [teratogens] in utero ……Delivery complications ……Congenital abnormalities / illness ……Very difficult temperament / extreme crying ……Very lethargic / non-responsive ……Resists holding / hypersensitive to touch ……Chronic maternal stress during pregnancy ……Head injuries ……Regulatory / sensory integration disorder ……

2. Parental History and Current Functioning:Mental illness, including depressionSerious medical condition ……

Own mother mentally ill / substance abusedParents seem incoherent or confused ……Developmental delay / learning disability ……Criminal or young offender’s record ……Previous child has been in foster care or adopted ……Mother experienced the death of a child ……Previous child has behaviour problems ……

Alcohol and / or drug abuse (current or past)History of physical or sexual abuse, witnessing violence, neglect or loss.Absent parent or step-parent (i.e. non-biologically related)Presence of an acute family crisis ……

3. Interactional or Parenting Variables:Lack of sensitivity to infant’s cries or signals ……Negative affect openly shown towards child ……Physically punitive towards child ……Lack of vocalisation to infant ……Lack of eye-to-eye contact ……Negative attributions made towards child, even if ‘jokey’ ……Lack of preparation during pregnancy ……Lacks knowledge of parenting and child development ……Infant has poor physical care (e.g. dirty and unkempt) ……Does not anticipate or encourage child’s development ……Quality of partner relationship, undermined or unsupported ……

Infant a victim of maltreatment, emotional abuse or neglectLack of consistent caregiver for infant ……

4. Socio-demographic Factors:Chronic unemployment ……Inadequate income / housing ……Frequent moves / no telephone ……Low educational achievement ……Single teenage mother without family support ……

Any violence reported in the family, especially if witnessed by childSevere family dysfunction ……Lack of support / isolation ……Recent life stress (e.g. bereavement, job loss, immigration) ……


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Appendix 2D

Maternal Attitude Scale (Bor et al, 2003]

Mother’s name ______________________ Baby’s name ________________

Date __________________

Below are a number of statements about your baby or infant and how you feel about him or her. Please answer each statement by putting a circle around the answer which best describes how you feelat the moment.

1. Caring for my baby is very satisfying

Strongly Agree Agree Neutral Disagree Strongly Disagree

2. I feel so angry that sometimes I could smack my baby.


3. My baby makes me feel too tired.


4. My baby is so good I hardly know he/she is there.


5. Sometimes I feel like hitting my baby.


6. I feel fed up looking after my baby all day.


ScoringScore Item 1 & 4 4-3-2-1-0 (Strongly agree to strongly disagree)Remaining items are scored 0-1-2-3-4 Higher scores represent a more positive attitude.Maximum = 24, minimum 0 Mothers scoring in the lowest 10th percentile (Total 3 or less) considered at risk.

References

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Appendix 2D

Bor, W., Brennan, P.A., Williams, G.M., Najman, J.M., O’Callaghan, M. (2003). A mother’s attitude towards her infant and childbehaviour five years later. Australian and New Zealand Journal of Psychiatry, 37, 748-755.

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http://www.ncbi.nlm.nih.gov/pubmed?term=Cole%20RE%5BAuthor%5D&cauthor=true&cauthor_uid=10414010

http://www.ncbi.nlm.nih.gov/pubmed?term=Tatelbaum%20RC%5BAuthor%5D&cauthor=true&cauthor_uid=10414010

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http://www.ptsd.va.gov/professional/articles/article-pdf/id26676.pdf

http://www.ncbi.nlm.nih.gov/pubmed?term=Luoma%20I%5BAuthor%5D&cauthor=true&cauthor_uid=20723997

http://www.ncbi.nlm.nih.gov/pubmed?term=Kaukonen%20P%5BAuthor%5D&cauthor=true&cauthor_uid=20723997

http://www.ncbi.nlm.nih.gov/pubmed?term=Guedeney%20A%5BAuthor%5D&cauthor=true&cauthor_uid=20723997

http://www.ncbi.nlm.nih.gov/pubmed?term=Salmelin%20R%5BAuthor%5D&cauthor=true&cauthor_uid=20723997

http://www.ncbi.nlm.nih.gov/pubmed?term=Tamminen%20T%5BAuthor%5D&cauthor=true&cauthor_uid=20723997

http://www.ncbi.nlm.nih.gov/pubmed?term=Tamminen%20T%5BAuthor%5D&cauthor=true&cauthor_uid=20723997


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APPENDIX 3 – Section 1

Quality and training of the workforce

Core knowledge

Knowledge that informs interactions with infants and toddlers:

1. Has an understanding of the link between feelings, needs and behaviour, including the recognition that all behaviour is communication (and not just something to be controlled).

2. Has an understanding of proactive, authoritative and positive approaches to boundary setting.3. Has an understanding of the importance of reciprocity, empathy and containment from all

parents/caregivers, and their impact on physical, social and emotional development and future health inadulthood.

4. Understands the fundamental importance of the parental (or caregivers’) relationship to their baby, frompregnancy and throughout infancy.

5. Is able to identify harmful influences on the unborn baby, infant and/or toddler – i.e. alcohol andsubstance misuse, domestic abuse, parental mental ill health.

Knowledge of child development from pre-birth to three years:

1. Has an understanding of child development, including social and emotional development, andappropriate expectations of individual infants and toddlers.

2. Has an understanding of attachment and how it links to relationships.3. Has an understanding of baby, infant and toddler brain development (and recognises that this work is

constantly evolving and therefore requires regular professional update).4. Has an understanding of the cultural, social and emotional factors which may contribute to common

behavioural problems in children under three years, such as feeding, toilet training, sleeping etc., andknows how to support parents in responding to these concerns.

5. Has an understanding of the importance of a preventive approach towards child and family work andunderstands the need to intervene early to prevent the escalation of concerns and maltreatment.

Interface with safeguarding knowledge:1. Recognises their professional role to intervene actively where 'clues' to poor attachment are noted.2. Has an understanding of factors creating social, emotional, economic and physical pressures and how

the complexity of family health needs may impact on their ability to be effective as parents.3. Has an understanding of the ways in which family strengths and protective factors interact with risks,

harm and needs – is able to apply a theoretical model to practice that recognises ‘good enough

parenting’ and where the statutory need for professional intervention (including on the child protection

threshold), lies.4. Has a theoretical understanding of the ability within families to change behaviour – parenting risks and

protective factors are dynamic and subject to change. Where families need to make changes to ensurethe best outcomes for their child, there is an understanding that this needs to be at a sufficient pace tomeet the needs of the infant /toddler.

5. Has an understanding of the levels of stress that are toxic to the unborn baby, the infant and the toddler, either through direct experience or via stress in the mother or primary care giver.

6. Has an understanding of the benefits of working with multidisciplinary, professional practitioners andhow to access a range of multi-agency support services in active partnership with parents.

Core SkillsDemonstrates the aptitudes, qualities and skills associated with an emotionally competent professionalpractitioner – i.e. emotionally mature and contained.

Interactions with infants and toddlers1. Ability to observe the interaction/relationship between parents and children.2. Ability to support and enhance infants’ and toddlers’ physical, social and emotional development.


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Skills to intervene in child development, from pre-birth to three years1. Ability to provide a confident level of advice (or education) to parents or parents-to-be, regarding the

parenting role and the vital importance of their relationship to their infant and, for 2 parents/carers, witheach other (including reciprocity, empathy and containment, as well as positive approaches to boundarysetting).

2. Has skills to assist and support the relationship and the attachment between parent and infant and/or toddler – i.e. able to model empathy and containment to parents and infants/toddlers.

3. Has the ability to connect and develop warm, nurturing and stimulating relationships with infants andtoddlers that are ‘tuned into’ the needs of each individual child.

4. Ability to work as a member of a team, including as a fully participating member of a multi-disciplinary ‘team around the child’.

o Considers asking for help and support as a strength. 5. Demonstrates capacity in professional reflection and utilises supervision process appropriately, i.e:

o Is able to reflect on the impact on their own childhood and life experience;o Is able to reflect and learn from their current work experience;o Assumes professional responsibility and arrives prepared for supervision sessions;o Shows signs of incremental professional growth and progression.

Skills to form empathetic relationships with parents in a professional capacity1. Ability to listen to parents and use clear, jargon-free language in all communication.2. Ability to form a meaningful partnership with all parents in an open, honest and respectful manner that

engenders respect and maintains dialogue throughout contact.3. Ability to form and maintain empathetic relationships with parents in a professional capacity.4. Demonstrates an ability to work with the development of the family/professional relationship, including

the building of confidence and trust.5. Demonstrates the ability to take a proactive approach to ensuring services are inclusive, i.e. able to

recognise and work with parents from a diverse array of cultural, religious and social backgrounds, including the ways in which this might impact on the engagement process.

6. Demonstrates an awareness of their own beliefs, values, judgements, feelings, needs etc., and those of others, and ways in which these impact on their professional interaction with infants and their parents.

7. Ability to identify, discuss and raise concerns with parents about the growth, development and well-being of their child.

8. Ability to recognise and work with the strengths, skills and expertise of parents and families, includinghow to work with parents to improve their effectiveness and enable them to believe they can makechanges in their own lives and those of their children.

9. Has skills and professional confidence to communicate ‘the unsayable’ with parents, in such a way that

they can take this on board and not be offended and undermined.10. Ability to maintain neutrality and to demonstrate empathy in their connection and relationships with

others.11. Ability to anticipate and work with barriers to parents’ understanding and engagement with services and

has the requisite skills to adapt professional approaches, as appropriate.12. Ability to recognise possible emotional or mental health difficulties in parents, seek guidance and refer

as appropriate.13. Ability to recognise patterns of avoidance, ambivalence, confrontation and violence in parents'

relationships and/or towards professionals; can evidence this, seek professional guidance and refer asappropriate.

14. Ability to support confidently the resolution of conflict.


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APPENDIX 3 – Section 2

Professional Reflective Supervision

This Section is intended as a guide to Professional Reflective Supervision and is presented as a sister to thepreceding section on the core knowledge and skills for the early years’ sector.

This diagram illustrates the system for focus during professional supervision. The arrows represent being able tocommunicate (represented by an arrow) and the capacity to receive the communication and convey anunderstanding of the communication (represented by an arrow). Implicit within this is the capacity to be in tunewith one another.

The diagram demonstrates that similar elements of a relationship occur within the parent/infant relationship as inthe parent/practitioner relationship, practitioner/team relationship and the practitioner/supervisor relationship

Baby/child

Parent/ Carer

Practitioner

Team

Supervisor

Organisation


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Core principles

This model for Professional Reflective Supervision includes the same underpinning principles as contained inSection 1 above.

1. All practitioners working with infants and their families need a reflective space with another person, asupervisor, coach or mentor, to understand and process their work.

2. All supervisors need to be trained in a reflective model of supervision, including the coaching dimension. Whatever the training option selected, it is essential that the central focus is upon the quality of therelationship.

(NB To achieve coverage, this could include aspects of peer observation/modelling, coachingskills and abilities and e-learning. It is essential that Supervisors are assessed as competent)

3. Supervision should be recognised as a fundamental structure to support high standards of professionalpractice. Supervision should therefore be prioritised, regular and uninterrupted.

4. Supervision sessions should be consistent in approach, style and the person (Supervisor), providing thesupervision. As far as practicable, any change of Supervisor should include a carefully managedtransition.

5. The frequency of supervision depends on the demands of the work and the experience of thepractitioner. New practitioners will require more supervision. We suggest a minimum of once a month.

6. Recognised as a cornerstone to high standards, supervision should be well structured, purposeful andthoroughly prepared for by both Supervisor and Supervisee.

7. Supervision should be supported by a written agreement, agenda and record, which document theprocess to be followed by Supervisee and Supervisor. These records should be signed off by both theSupervisor and Supervisee. Should an issue arise regarding professional performance this should berecorded, with care given to both parties’ views being noted. If a matter cannot be resolved and either party is left with a grievance, a third party should be approached to mediate a resolution.

8. Supervision should be understood as an integral part to professional practice with infants and their parents and embedded within the organisational ethos and philosophy. Agreement about what aspectsof supervision are confidential and which are shared should be explicit.

9. Supervision is not optional. The time taken will pay for itself in a better developed workforce, better quality services and improved outcomes for parents and children.

10. When there is regular supervision structure in place for the organisation, issues underlying behaviour concerning competence, ‘stuckness’ etc. are addressed promptly. As a consequence, the need for

disciplinary action often reduces substantially.

Definition of Reflective Supervision

Professional supervision provides the opportunity for facilitated, in-depth reflection on issues affecting practice. Itis a process whereby the supervisor can clarify the dynamics that operate between the family and the superviseeand can ensure that safe practice is maintained for both the family and the practitioner. Supervision includesdiscussion and problem-solving for both administrative and clinical tasks. The process includes devoting time toexplore the thoughts and reactions of the practitioner to the intensity and specific focus of the work. Thisapproach is often described as reflective supervision.

The Components of Supervision

Professional supervision provides the opportunity for both Supervisor and Supervisee to reflect on thepractitioner’s work with infants, their parents, wider families and their joint work with other professional

practitioners within the network. Supervision includes the following functions:-

- Managing performance (how well the supervisee has carried out their required duties and role. This willinclude day-to-day practice, sickness, absences, competency discussions and, on occasions, annualappraisals).

- Supporting development (what skills and knowledge the supervisee needs to carry out their dutieseffectively; identifying training needs and opportunities which support continued professionaldevelopment).

- Personal support (recognising the emotional impact of the work and the impact of personal issues for the supervisee and ensuring that the supervisee has emotional intelligence).


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- Mediation (acting as a bridge between the organisation and the supervisee, ensuring the supervisee isengaged with the organisation).

There are also components within the supervisory relationship that serve to promote effective supervision andsafe practice, including:

o The supervisor should be open to hearing the story and experiences of the supervisee and askingexploratory questions to support an open discussion of the issues.

o The supervisor should endeavour to provide the opportunity for reflection in which the supervisee canreflect and consider their experiences in the light of the dynamics that are operating betweenthemselves and the family/infant. This is also an opportunity to examine any cultural or individual biasthat may affect the supervisee’s ability to carry out their duties.

o Having heard the story and reflected on the issues, the supervisor and supervisee should then consider the issues in the light of recent relevant research and knowledge and form a view regarding future plansand actions.

o Supervision will also include a process for making decisions, forming and reviewing plans and thenconsidering resources needed to put these plans into action.

Both supervisee and supervisor contribute to an effective supervisory relationship. They should both recognisethe power differentiation between Supervisor and Supervisee and seek to maintain equity.

Professional supervision does not fulfil a therapy function for either Supervisee or Supervisor.

The Role of the SupervisorEssentially the supervisor fulfills a supportive, normative, restorative and informative function. Their role is to:

o Work in partnership with the supervisee.o Familiarise themselves with the role and responsibilities of the supervisee.o Provide the supervisee with uninterrupted time and a safe space for the session.o Listen with attention to the issues and experiences of the supervisee, reflect back their observations and

ask challenging questions that enable the supervisee to reflect on what is happening that is working, what is not working and to support them in seeing the way forward.

o Be honest and straightforward, compassionate in an empathetic way, is able to view situations from avariety of perspectives and uphold a duty of care to the supervisee, the infants and families.

o Give reference to a professionally agreed code of ethics.o Keep content of sessions confidential in line with organisational policies.

The Role of the SuperviseeAs a practitioner working with infants and their parents, the supervisee should recognise that supervision is anintegral part of their professional practice. It is a means by which they reflect upon and account for their approachand interventions. Their role is to:

o Be committed to the process of supervisiono Keep appointments o Be willing to engage in reflectiono Be open and honest and committed to work within a professional and ethical frameworko Be prepared for the session ahead of time (having already considered their work load, what is working

well, what is not working well and what they are concerned about and therefore intend to take to thesupervision session)

Professional Supervision within a group care environmentIt should be recognised that those working within a group care environment, including in early years’ settings, areaccountable for their own practice and that of their colleagues. They have a key role to play in observation andmonitoring professional practice within the setting. This includes professional interaction with infants, their parents and with each other, as colleagues. It is the responsibility of all practitioners to question and, in somecircumstances, intervene where they observe a child, parent and/or colleague is struggling, distressed and/or at risk of harm. It is also their responsibility to raise concern regarding their colleagues’ practice with their

supervisor.


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NB. This may be outside of the scheduled supervision appointment, dependent on the level of risk posed andseriousness.

The need for structured supervision systemEffective supervision is one of the keys to delivering positive outcomes for everyone. It is important for allorganisations to have an unambiguous commitment to a well-structured supervision system, provided in thecontext of a clear organisation approach/ culture. To ensure its continued relevance and appropriateness, anannual review is essential, combined with monitoring and quality assurance checks to confirm the validity of thesupervision system.

A sample procedure for setting up a Supervision System is included at the end of this document.

In designing a supervision structure, thought should be given to how the organisation’s ethos, culture, principles

and values will be reflected.

It also needs to be recognised that a balance needs to be struck between providing structure and the provision of a reflective space. Sessions that are too structured and goal-orientated leave no time for reflection. This is thesame issue when working with families, balancing a relationship model with structure and goals.

Models of SupervisionThere are numerous models for supervision, in addition to the traditional 1:1 Supervisee and Supervisor approach. These include options for working in groups, where the learning ‘edge’ in building professional

confidence and competence might be optimised through the group dynamic. Examples are:

o Action learning setso Peer circleso Peer : peer supervision

The underpinning principles of supervisionThese principles for supervision have been mapped with Section 1 above:

1. Has an understanding of the link between feelings, needs and behaviour, including the recognition that all behaviour is communication (and not just something to be controlled).

2. Has an understanding of proactive, authoritative and positive approaches to boundary setting withinsupervision.

3. Has an understanding of the importance of reciprocity, empathy and containment in supervision andtheir impact on the practitioner’s development.

4. Understands the need for containment in stressful situations in order to restore the practitioner’s ability

to think. Providing space to process the particular work experience, including the emotional experienceor anxiety, enables the practitioner to think about and understand the work experience, leading toappropriate intervention.

5. Understands that sometimes current or past experiences in the practitioner’s life may be impacting their

ability to think in certain situations. Sometimes recognising this is enough to restore the ability to think. It should be recognised that professional supervision is not therapy.

6. As with work with parents and infants, is able to set up a ‘safe space’ for supervision, with protected

time, a respectful and trusting relationship and with the emotional space to be able to listen to thepractitioner.

7. As with parents and infant, understands the importance of reciprocity within supervision, to be attuned tothe practitioner.

8. Knows how to get support if overwhelmed him/herself, in order to be able to provide reflectivesupervision.

9. Has an understanding of the need to assess the developmental needs of the supervisee and canpromote and support opportunities for learning.

10. Has knowledge and experience of various models for supervision, including those working on a one toone basis, with groups and between peer groups.


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Sample procedure for setting up a Supervision System


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APPENDIX 4 – The economics of early years’ investment

SECTION I – International studies

How advisable is it for national or local policy-making bodies in the UK, with responsibility for child health or welfare, and control over spending, to switch investment more heavily to the early years? We have conducted areview of both UK and international studies which look at this question from a number of different but complementary perspectives. This Section focuses on the findings of the international studies. Section 2summarises the UK studies.

Overview

The short answer is there is general expert consensus that it is somewhere between economically worthwhileand imperative to invest more heavily, as a proportion of both local and national spend, in the very earliestmonths and years of life. Nine approaches to evaluating the outcomes of early years’ investment are reviewedhere.

o Every approach – even the most cautious and circumspect in its recommendations – finds that returnson investment on well-designed early years’ interventions significantly exceed their costs.

o The benefits range from 75% to over 1,000% higher than costs, with rates of return on investmentsignificantly and repeatedly shown to be higher than those obtained from most public and privateinvestments.

o Where a whole country has adopted a policy of investment in early years’ prevention, returns are not

merely financial but in strikingly better health for the whole population. The benefits span lower infant mortality at birth through to reduced heart, liver and lung disease in middle-age.

o The logical links between the investments and the health benefits are described in the ‘AdverseChildhood Experiences’ (ACE) studies which reveal that for every 100 cases of child abuse society can

expect to pay in middle or old age for (amongst a wide range of physical and mental healthconsequences):

one additional case of liver disease two additional cases of lung disease six additional cases of serious heart disease, and 16% higher rate of anti-depressant prescriptions (Felitti and Anda, 2009)

o None of the estimates takes account of the economic value of the knock-on effect that child abuseaverted in one generation will itself result in a cumulative reduction in this dysfunction during futuregenerations.

Summary of studies reviewed

RAND/Karoly et alThe RAND study by Karoly et al (2005) found:

o Statistically significant benefits being delivered in at least two-thirds of 20 early years’ programmes, in

seven different domains of health and welfare. o With the exception of two programmes where costs either exceeded their benefits, or could not be

monetised, eight cost benefit analyses of early years’ programmes, or meta-analyses of suchprogrammes, showed benefits significantly exceeding costs, with payoffs per dollar invested rangingfrom $1.80 to $17.07.

o The estimated net benefits ranged from $1,400 to nearly $240,000 per child.o The greatest benefits come from programmes with long-term follow-up. o The authors concluded:

‘benefit-cost estimates for effective programs are likely to be conservative’

Reynolds et alo Reynolds et al’s (2011) intensive analysis of the Chicago Child-Parent Center Program found benefits of

more than $80,000 per child, with $10.80 of benefits per $1 invested.o They also found that children with four or more family risk factors yielded almost double the benefits of

those with fewer ($12.8 vs. $7.2 per $1 invested).o Children from the highest poverty neighbourhoods had returns more than four times higher than those

from less disadvantaged areas.


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o The Chicago findings are additionally significant because they come not from a pilot study but viaevaluating a practice embedded in the Chicago Public Schools’ system for over four decades.

Reynolds also identifies a further early years’ programme, not included in the RAND analysis:

o The prenatal and infancy and nutrition programme, Women, Infants, and Children (WIC) whichreportedly saved $3.07 per $1 invested in reduced medical costs in the first year of life (Avruch & Cackley, 1995). This is likely to be a rather conservative estimate of its lifetime benefits.

Federal Reserve Bank of Minneapolis/Rolnick & GrunewaldA different perspective on the issue is provided by bankers from the Federal Reserve Bank of Minneapolis, Rolnick and Grunewald (2003) who calculated that:

o The significantly higher returns found from early years’ programmes compared to most publicinvestment is evidence that society is not spending enough on the early years – and that to do so issound financial policy.

o Internal rates of return for those early years’ programmes evaluated exceed both: stock market returns, and returns from typical public policy investments.

They would also significantly exceed returns from many UK large-scale public investments, including (for example) the high speed HS2 rail link.

James HeckmanAnother viewpoint from outside the sector is provided by the Nobel Laureate economist James Heckman, whosefocus is on economic efficiency and skill formation, rather than avoiding social dysfunction. Heckman (2008) asserts that:

o Financial returns on early years’ investments are highest for age 0-3, and diminish progressively aschildren become older.

o His persuasive argument in logic for why this should be so is supported by reference to the principle that learning begets learning (i.e. early benefits become cumulative) and (disappointing) economicevaluations of such later interventions as attempts to skill-train adolescents.

o Society is demonstrably under-investing in the early years. o Because early years’ interventions both promote economic efficiency and reduce lifetime inequality, they

provide policy makers with a rare opportunity to spend money in a way that delivers social andeconomic benefits at the same time.

Harvard UniversityThe Harvard Center on the Developing Child at Harvard University (2007, 2010) bases its case on the science of neurobiology:

o Because the infant (and human) brain is built from its basic structures upwards, each new stagedepends on the quality of the preceding stage.

o This means creating the right conditions for early childhood development is likely to be more effectiveand less costly than addressing problems at a later age.

o The basic principles of neuroscience and the process of human skill formation indicate that early years’

intervention for the most vulnerable children will generate the greatest payback. o Also, although the large number of children and families who could benefit from additional assistance

will require significant increases in funding, extensive research indicates that investment in high qualityinterventions will generate substantial future returns through:

increased taxes paid by more productive adults, and significant reductions in public expenditure on special education, welfare assistance, and

incarceration. o Policy makers can achieve greater return on investments in early childhood education for children from

families with low incomes and limited parent education than from remedial programs for adults withlimited workforce skills.

While the comparison is different, this latter point echoes the finding of Reynolds et al, that returns are muchhigher for families from poverty neighbourhoods and those with more family risk factors.


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SwedenSweden adopts a whole country approach which follows the principle of early years’ prevention. The payoff fromthis policy at a national level is shown in:

o Infant mortality half of that in the UK.o Obesity levels less than half those in the UK.o Teenage pregnancy one quarter of the level in the UK.o Deaths from cancer and smoking-related diseases about 20% lower than the UK.o Deaths from circulatory diseases 25% lower than in the UK.o Deaths from chronic liver disease more than 50% lower than in the UK.

Cohen et al – view from the other end of the perspectiveIn their studies Cohen, Piquero and Jennings (2010) take a different approach by estimating the lifetime costs of bad outcomes for at risk youths, and offering an innovative methodology for assessing early years’ interventionswhereby their cost-effectiveness can be judged by the minimum number of cases of child abuse, drug abuse or criminality a given intervention can be reliably predicted to prevent.

Applying the costs per family of such typical early years’ interventions as First Steps in Parenting, Nurse FamilyPartnership, the Sunderland Infant Project, Circle of Security, Mellow Parenting, Triple P etc to the Cohen, Piquero and Jennings methodology suggest that such programmes need to be successful in preventing childabuse in only 2% of their participants to pay for themselves, without taking account of what they may deliver inreduced alcohol or drug abuse, future domestic violence or such other benefits as reduced medical and welfarecosts.

Washington State Institute for Public Policy (WSIPP)The Washington State Institute for Public Policy takes a rigorously conservative stance to programme evaluation, based on an absolute ‘no false positives’ approach. It arguably under-states by some margin the value of preventing child abuse and heavily discounts, or disqualifies, the research findings of many early years’

practitioners. Even with these restrictions, it still finds positive benefit to cost ratios for a range of early years’

programmes, ranging from $1.75 per $1 invested from Parents as Teachers through $3.23 per $1 invested for Nurse Family Partnership and $7 for Parent Child Interaction Therapy to $10.32 per $1 invested for Level 4Group Triple P.

Their methodology and mandated legislative focus lead them to recommend many more teen than early years’

programmes. Such interventions should not be seen in terms of either/or; both provide higher returns to societythan the bulk of public and private investments.

The following provides further detail on the evaluations above:

Review of cost benefit studies of early years’ programmes

A) Rand review of early years’ investments

The PNC Grow Up Great initiative is a ten-year, $100-million programme to improve school- readiness for children from birth to age 5. PNC Financial Services Group Inc partnered with Sesame Workshop (producers of Sesame Street) and Family Communications Inc, producers of Mister Rogers’ Neighborhood, to develop content for the initiative, guided by an advisory council of experts in the early childhood field.

As part of the initiative, PNC asked the RAND Corporation to prepare a thorough, objective review and synthesisof current research on interventions in early childhood, looking at:

o the potential consequences of not investing additional resources in the lives of children – particularlydisadvantaged children – prior to school entry;

o the available range of early intervention programmes, focusing on those rigorously evaluated;o the demonstrated benefits of interventions with high-quality evaluations and the features associated with

successful programmes;o the returns to society associated with investing early in the lives of disadvantaged children.

Carried out by Karoly, Kilburn and Cannon (2005), the study notes that disadvantages in early childhood havesignificant implications for how well prepared children are when they enter school, not only in cognitive skills but also in socialisation, self-regulatory behaviour, and learning approaches. Children with more disadvantaged


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backgrounds enter school with lower levels of knowledge and social competencies, and achievement gaps tendto widen over time. Children from disadvantaged backgrounds experience higher rates of special education useand dropping out of school; lower rates of employment and higher rates of welfare dependency, delinquency andcrime. The authors comment:

Even if only a portion of these detrimental outcomes in childhood and adulthood can be averted, thebenefits may be substantial

Turning to evaluation, the study observes that while many early childhood interventions have been implemented,only a relatively small subset have been evaluated using scientifically sound methods. After rigorous review, theauthors identified published evaluations for 20 early childhood programmes with well-implemented experimental, or strong quasi-experimental, designs. The study then examined the following benefit domains:

o cognition and academic achievemento behavioural and emotional competencieso educational progression and attainmento child maltreatmento health, accidents and injurieso delinquency and crimeo social welfare programme useo labour market success

Statistically significant benefits were found in at least two-thirds of the programmes reviewed in every one ofthese benefit domains, with one exception (social welfare programme use). (See Tables S.2 and S.3 of theoriginal Karoly et al report.) The magnitudes of the favourable effects were often (though not always) sizable.

Seven of the 20 programmes studied had been subjected to cost-benefit analyses. The authors summarised thefindings of these studies, together with benefit-cost meta-analyses of home visiting programmes for at riskchildren and early childhood education programmes for low-income 3-4-year-olds, based on rigorous outcomeevaluations. The results are summarised in the table below, arranged by age of participants at the time of the last follow-up (adapted from Table S.4 in the original):

Benefit-Cost Results for Selected Early Childhood Intervention Programs

Program Age at Last Follow-Up

ProgramCosts per Child ($)

Total Benefitsto Society per Child ($)

Net Benefitsto Society per Child ($)

Benefit-Cost Ratio

Follow-Up During Elementary School YearsComprehensive ChildDevelopment Program

5 37,388 –9 –37,397 —

HIPPY USA 6 1,681 3,032 1,351 1.80Infant Health and Development Program

8 49,021 0 –49,021 —

Follow-Up During Secondary School YearsNurse Family Partnership —higher-risk sample

15 7,271 41,419 34,148 5.70

Nurse Family Partnership —lower-risk sample

15 7,271 9,151 1,880 1.26

Nurse Family Partnership — fullsample

15 9,118 26,298 17,180 2.88

Home Visiting for at risk mothersand children (meta-analysis)

Varies 4,892 10,969 6,077 2.24

Follow-Up to Early AdulthoodAbecedarian 21 42,871 138,635 95,764 3.23Chicago Child-Parent Center 21 6,913 49,337 42,424 7.14Perry Pre-School (includingintangible crime costs)

27 14,830 76,426 61,595 5.15

Early Childhood Education for low-income 3- and 4-year-olds(meta-analysis)

Varies 6,681 15,742 9,061 2.36

Follow-Up to Middle AdulthoodPerry Preschool 40 14,830 253,154 238,324 17.07

NOTES: All dollar values are 2003 dollars per child and are the present value of amounts over time where futurevalues are discounted to age 0 of the participating child, using a 3 percent annual real discount rate.


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Because of differences in evaluation methodology (such as which benefits are measured and monetised) theauthors caution that these results cannot identify exactly which programmes have the highest returns. However, they can demonstrate whether, in principle, early childhood intervention programmes generate benefitsoutweighing their costs.

One of the programmes evaluated (the Comprehensive Child Development Program, or CCDP) was not shownto be effective, because it could not generate net economic benefits. Another (the Infant Health and Development Program, or IHDP) had favourable effects as of the follow-up at age 8, for example in IQ and maths achievement for heavier low birth weight (but not very low birth weight) babies, but the outcomes assessed could not betranslated into dollar savings. For the remaining studies (including the meta-analyses), the estimates of net benefits ranged from about $1,400 to nearly $240,000 per child. The returns to society for each dollar investedranged from a low of $1.26 to a high of $17.07. Positive net benefits were found for both expensive and low-cost programmes. Favourable returns were found both for home-visiting and parent education programmes as well ascombination programmes.

The largest benefit-cost ratios were found in programmes with longer-term follow-up because they allowedmeasurement at older ages of outcomes that most readily translate into dollar benefits. These outcomes includededucational attainment, delinquency, crime and earnings. The authors conclude:

‘Not only do the studies … based on long-term follow-up, demonstrate that the benefits from earlyinterventions can be long-lasting, they also give more confidence that the savings the programsgenerate can be substantial’

and observed that:

‘benefit-cost estimates for effective programs are likely to be conservative’

(because so few are funded to track the long-term outcomes and so translate them to dollar benefits).

B) Large-scale city-wide approach

Recognising Karoly et al’s point that evaluations which take account of benefits over a longer time scale willprovide more accurate pictures of cost benefit analysis, Reynolds et al (2011) carried out a cost benefit analysisof the Chicago Child-Parent Center (CPC) Early Education Program using data collected up to age 26. The 2011analysis was able to use actual rather than projections for earnings and adult crime prevention outcomes andalso included benefits on health and wellbeing, including mental health and substance use.

The analysis showed that preschool participants in the CPC had:

o significantly higher rates of high school completiono completed more years of educationo significantly lower rates of felony arrest o higher rates of health insurance coverage and lower rates of depressive symptoms, as assessed from

ages 22 to 24o lower rates of daily smoking and substance misuse by age 26

Juvenile benefits included lower rates of:

o special education placemento child maltreatment ando out-of-home placement, and juvenile arrest

Percentage reductions over the comparison group ranged from one third to one half.

A benefit to cost analysis of the preschool programme showed a ratio of $10.80 benefits per $1 invested with anaverage economic return to society of $92,220 for a cost of $8,512 per participant.

Benefits to the public, excluding earnings and participant benefits, totalled $61,246 with a benefit to cost ratio of $7.20 per dollar invested.

Children with four or more family risk factors received nearly double the benefits of those with fewer such riskfactors ($12.80 vs. $7.20), and children from the highest poverty neighbourhoods achieved returns more thanfour times higher than those for children from less disadvantaged areas.


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Estimates were robust across a wide range of analyses, including Monte Carlo simulations.

Reynolds et al also evaluated the benefits of intervention at school age and found that these also justified thecost of the investment – but with significantly lower returns than the preschool programme ($1.70 to $2.00 per $1invested). Here again, returns were much higher for disadvantaged children.

The Reynolds findings are significant. The Chicago Child-Parent Center programme has been established in theChicago Public Schools’ system for over four decades. Although costing moderately more than other contemporary federal and state-financed programmes, the CPC programme has generally similar teacher qualifications, class sizes and ratios, instructional approaches, school-based structures, and scope of services.

The CPC findings reinforce the Karoly conclusions that there can be high economic returns from preschoolprogrammes for children at risk, and suggest these can apply even when programmes are implemented on alarge scale.

Reynolds et al also report on a very early intervention programme, not included in the Karoly analysis: theprenatal and infancy nutrition programme Women, Infants, and Children (WIC) which reportedly saved $3.07 per$1 invested in reduced medical costs in the first year of life alone – due to reduced rates of low birth weights(Avruch & Cackley, 1995).

A number of studies have found links between low birth weight and such expensive problems in later life as highblood pressure and coronary heart disease (Barker 1995). Lewitt et al (1995) calculated that low birth weight children incur additional annual costs of $1,500 (in 1988) up to the age of 15 in terms of health care andeducation. Low birth weight has also been negatively correlated with adult health, qualification and labour market attainment (Case et al, 2005, Currie and Hyson, 1999) hence the benefits of the WIC programme are probablyvery significantly understated.

C) Bankers’ eye view on where public spending should be focused

A hard-nosed banking perspective on the economics of early years' investment is provided by Rolnick andGrunewald (2003). Art Rolnick is Senior Vice President and Director of Research, and Rob Grunewald isRegional Economic Analyst at the Federal Reserve Bank of Minneapolis. They show that investment in humancapital breeds success for the overall economy. They contrast the ratio of earnings for those with degreescompared to the average worker prior to 1983 (40% higher) and in the 2000s (closer to 60% higher). Thepremium for an advanced degree has grown even more, from 60% to over 100%.

Rolnick and Grunewald compare the value of investment in early childhood development with investments inother public projects. Well-grounded benefit-to-cost ratios are seldom calculated for public projects, but analternative measure – the internal rate of return (IRR) or compound return on the project – can be used tocompare the financial return to public as well as private investments.

Rolnick and Grunewald converted the paybacks from the Perry preschool programme and arrived at an IRR of16%, after adjustment for inflation. They also calculated that about 80% of the benefits went to the general public(e.g. students were less disruptive in class and committed fewer crimes), yielding over a 12% internal rate of return for society in general.

While the authors did not calculate the IRR for other early years’ development programmes, Reynolds et al dothis for the CPC preschool programme, arriving at an IRR of 18% (Reynolds et al, 2011).

Rolnick and Grunewald observe that preschool investment returns are much higher than those achieved by other public investments, or by most private industry investments. Commenting on the large sums of money spent inthe US on supporting, or rescuing, underperforming businesses, in investments in sports stadia and other formsof public investment, they conclude that society is under-investing in the early years – otherwise the rates of return would be brought down by natural competition to a more equivalent level for society in general.

To put this method in perspective: the UK Department of Transport estimates the rate of return on the new HS2high-speed rail link at between £1.80 and £2.50 per £1 invested. In an analysis of 15 economic studies ofprogrammes from birth to age 9, Reynolds and Temple (2008) found an average economic return (expressed inpounds) of £2.83 per £1 invested for interventions implemented before age 5.

Rolnick and Grunewald conclude by recommending heavy public investment in early childhood development programmes.


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D) Study of the costs of failing to intervene early on the pathway to

dysfunction

Cohen, Piquero and Jennings (2010) stand on its head the question of how worthwhile it is to invest in earlyyears’ programmes,

Rather than wait a couple of decades for the results of a well-designed longitudinal study and cost benefit analysis, they propose the value of investments can be determined much more rapidly by knowing the cost of theadverse outcomes such programmes are designed to prevent, then calculating the rate of success required by aprogramme to justify its cost. If a programme’s success rate is clearly exceeding the requisite break-even point,we can judge it is a sound investment without waiting years to make the decision.

Cohen (1998) provided one of the most comprehensive attempts to calculate the costs of crime. His researchestimated that the typical career criminal caused $1.3 to $1.5 million in external costs. The overall estimate of the‘monetary value of saving a high-risk youth’ was put at between $1.7m and $2.3 million (per youth).

More recently Cohen and Piquero (2009) used a more comprehensive cost methodology plus new data on career offenders, and estimated the present value of saving a single high-risk youth (as of birth) at between $2.6 and$4.4 million.

In a follow-up pape, ‘Estimating the Costs of Bad Outcomes for At Risk Youth and the Benefits of Early ChildhoodInterventions to Reduce Them’, Cohen, Piquero, and Jennings (2010) conducted a thorough analysis of a rangeof adverse outcomes for society (and the individual), placing a monetary value on each.

The authors conducted a literature search through a series of electronic databases to identify potential earlychildhood prevention/intervention programmes with long-term results on at least one rigorous evaluation relatingto the following outcomes:

o crime/delinquency; o education; o alcohol and drug abuse; o smoking; o child abuse and neglect;o physical health problems; ando teenage pregnancy.

They then required the study to contain, or be capable of:

o a well-constructed comparison group;o quantifiable evidence to determine whether a programme was successful at preventing/reducing the

relevant outcomes of interest;o replication in ‘real-world’ settings.

Following an exhaustive search, 14 well-designed studies with long-term follow-up results met the selectioncriteria. The majority of these programmes started during pregnancy or at birth and followed the children (andsometimes the mothers) for a considerable time, ranging from 4 to more than 30 years. Most were home-visitation programmes, with some day-care/school-based programmes and some early parent trainingprogrammes (see original article for list). One programme was Australian (the Busselton Project), one wasCanadian (the Montreal Longitudinal Experimental Study) and the remainder were American.

Next, Cohen et al examined the costs of each social ill identified as being related to an at-risk childhood andconducted an extensive literature review on both the incidence of impacts and their costs. Their article takes 20pages to describe in detail their methodology for estimating the costs of each adverse outcome. We will not summarise their approach here other than to say it was conducted with considerable rigour.

Cohen et al estimate the following present value costs for the outcomes below:


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Adverse outcome Lifetime present value costcareer criminal $2.1-$3.7 milliondrug abuse c. $700,000alcohol dependence c. $700,000child abuse and neglect $250,000 to $285,000smoking $260,000diabetes $187,000asthma $144,000teen pregnancy $120,000 to $140,000coronary heart disease $127,000

One-time criminal offenders were estimated to cost $78,500 – thus crime has a range of costs between that lower sum, and the cost of a career criminal.

Cohen et al conclude:

‘properly designed programs and policies that focus on early childhood intervention have the potential toproduce significant social benefits’

Noting that the large-scale longitudinal data which, in a perfect world, would allow early childhood interventionprogrammes to be evaluated on the basis of their long-term [cost] effectiveness is hard to come by, they againstand the question on its head and propose the reverse approach of asking the question ‘how effective must aprogram be before it pays for itself?’

So, at a stroke, Cohen and colleagues resolve a major challenge for international policy makers! Instead of having to wait a decade or more, plus the expense of a Randomised Control Trial, before being able to judge thecost-effectiveness of relatively new or under-researched programmes, a judgment can be made in a fraction of the time if the operational effectiveness of the programme can be established. Provided this is greater than thebreak-even performance needed to justify the programme’s costs it can be judged to be cost-effective and worthyof investment.

They give as a theoretical example a programme found to reduce obesity in young children, with the expectationthat in turn this will reduce diabetes and heart disease over their lifetime. If the programme covered 1,000children at a cost of $1 million, one could calculate the break-even point at which the programme would pay foritself. Given an average cost of c.$150,000 per case of heart disease or diabetes, the programme could bejudged a success if it prevented seven cases (i.e. the benefits are 7 times $150,000 or $1.05 million). Thus if it works for 0.7% of the children in the treatment programme it can be judged to be cost-effective.

Based on the costs of early years’ programmes, and using Cohen et al’s estimates, the rate of effectiveness inpreventing cases of child abuse and neglect need be no more that 2% per participant for such programmes topay for themselves.

The Adverse Childhood Experiences’ studies

Another ‘avoidance of negative outcomes’ approach which is relevant to juxtapose with the work of Cohen et al isthe series of studies carried out by Vincent Felitti and colleagues in the Californian Adverse ChildhoodExperiences’ (ACE) studies. This was (and is) a major American epidemiological study providing retrospectiveand prospective analysis in over 17,000 individuals of the effect of traumatic experiences, during the firsteighteen years of life, on adolescent and adult medical and psychiatric disease, sexual behaviour, healthcarecosts, and life expectancy.

The ACE Study was carried out by Kaiser Permanente’s Department of Preventive Medicine in collaboration withthe US Center for Disease Control and Prevention (CDC). Subjects were Kaiser Health Plan patients – middle-class Americans, all with high quality health insurance. The participants were 80% white including Hispanic, 10%black, and 10% Asian; 74% had attended college; their average age was 57. Almost exactly half were men, half women.

There were 2 waves to the study, with 8 categories of ACEs studied in the first wave and two categories of neglect added (at the request of participants) in the second wave. ACEs in a general, middle-class populationwere unexpectedly high.

The researchers created for each individual an ACE Score, a count of the number of categories of adversechildhood experience during their first 18 years. The ACEs were captured in three groups – Abuse (emotional, physical and sexual); Household dysfunction (domestic violence, alcoholic or drug user in the home, household


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member imprisoned, household member chronically depressed, suicidal, mentally ill, or in psychiatric hospital, and child not raised by both biological parents); and Neglect (physical and emotional).

ACE Score does not tally incidents within a category; the occurrence during childhood or adolescence of any onecategory of adverse experience is scored as only one point. The ACE Score therefore can range from 0 to 8 or 10, depending on which stage of the study.

Only one third of this middle-class population had an ACE Score of 0; one in six individuals had an ACE Score of4 or more, and one in nine had an ACE Score of 5 or more. Women were 50% more likely than men to haveexperienced 5 or more categories.

The ACE Study matches retrospectively an individual’s current state of health and well-being against the ACE Score, and then follows the cohort forward to match ACE Score prospectively against:

o doctor office visits, o casualty visits,o hospitalisation, o pharmacy costs, ando death.

The prospective study has been running for fourteen years. Findings include:

o A proportionate relationship between ACE Score and depression (prescription rates for antidepressant medications), fifty to sixty years after the ACEs occurred. An analysis of population-attributable riskshows that 54% of current depression and 58% of suicide attempts in women can be attributed toadverse childhood experiences.

o Strong, proportionate relationships between ACE Score and the use of various psychoactive materialsor behaviours. Self-acknowledged current smoking, self-defined alcoholism and self-acknowledgedinjection drug use were strongly related in a proportionate manner to ACEs.

o The relationship of ACE Score to intravenous drug use was particularly striking. Male children with ACE Score of 6 or more had a 4,600% increased likelihood of later becoming an injection drug user, ascontrasted with an ACE Score 0 male.

o ACE Score was also related to the decades-later use of anti-psychotic and anxiolytic medicationso Poor self-rated job performance correlates with ACE Score.o Teen pregnancy and promiscuity (more than 50 sexual partners) were also proportionally related to ACE

Scoreo Miscarriage of pregnancy was related to ACE Score. o Four examples of the links between childhood experience and adult biomedical disease were the

relationship of ACE Score to liver disease, lung disease, coronary artery disease and autoimmunedisease

The ACE Score and the Prevalence of LiverDisease (Hepatitis/Jaundice)

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ACE Score

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ACE Score vs. COPD

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m

COPD


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ACEs Increase Likelihood of Heart Disease*

• Emotional abuse 1.7x• Physical abuse 1.5x• Sexual abuse 1.4x• Domestic violence 1.4x• Mental illness 1.4x• Substance abuse 1.3x• Household criminal 1.7x• Emotional neglect 1.3x• Physical neglect 1.4x

The researchers observe that while it might be thought that the relationship with lung or heart disease might simply reflect the links of ACE Score to levels of smoking, in fact the actual situation is more complex. For example, the study found a strong relationship of ACE Score to coronary disease, after correcting for all theconventional risk factors like smoking, cholesterol, etc. They hypothesised that this is likely to reflect the long-term effects of childhood stress, an assumption supported by recent research findings on the long-term healtheffects of maternal stress in pregnancy, where it has been found that this can have life-long adverse effects onchildren’s health and development through alterations to gene expression (epigenetics).

The ACE authors have begun a prospective analysis of adult death rates and their relationship to ACE Scores. However, there is already striking evidence. Between the ages of 19 to 34 participants in the medical exam, whohad an ACE Score of 0, outnumbered those with an ACE Score of 4, by just over 3 to 1. By age 50 to 64 theparticipants with a Score of 0 outnumbered those with a Score of 4 by just over 7 to 1. For participants in themedical exam aged 65 and over those with an ACE Score of 0 outnumbered those with a Score of 4 by over 17to 1. The researchers surmised that, quite simply, far more of those with a Score of 4 or more are dead. (Theresearchers looked for alternative explanations but the data did not support these.) The progression seems to be: ACE Score is strongly related first to health risks; then to disease; then to death.

The implications of the ACE Studies for national health policies are huge. They indicate that large cost savingscan be made over time by reducing the number of children suffering Adverse Childhood Experiences.

We know from much of our other research that the most effective time to intervene in a child’s life, or in theprogression of a family, to prevent ACEs, is before birth and in the first few years of life. The peak age for childabuse in the UK is 0-1 (DCSF, 2009; Welsh Government, 2012), and abuse and neglect are also significantlyhigher for 1-4 year olds than for older children (DCSF, 2009; Scottish Government, 2012; Welsh Government,2012).

To take just one example of the potential benefits by preventing ACEs from pre-birth onwards, the criminal justicesystem and National Health Service spend huge sums dealing with drug abuse, which is reported to cost the UK over £15 billion per annum (House of Commons Public Accounts Committee, 30th Report of Session 2009-10). Inthe ACE studies, the one sixth of individuals with 4 or more ACEs had 11 times higher levels of intravenous drugabuse than those with an ACE Score of 0. The researchers propose that alcohol and drugs are often used asself-medication by people who have suffered adverse childhood experiences. The ACE Studies indicate that a far more effective way to reduce drug abuse in society is to reduce ACEs rather than to wait for the misuse of drugsto emerge and then address those symptoms of a deeper malaise.

However, the work of the ACE researchers also indicates the potential for much shorter-term savings. At KaiserPermanente’s high-volume Department of Preventive Medicine they have used what they learned to expandradically the nature of their Review of Systems and Past History questionnaire.

Examiners were trained to ask questions relating to prior ACEs in medical exams and an impact was found: compared to the year before, a 35% reduction in visits to doctors’ surgeries was found in the year following theevaluation, visits to Accident and Emergency departments showed an 11% reduction and hospitalisationsdropped by 3%. The researchers believe patients respond positively when doctors recognise the true underlyingcauses rather than simply alleviating symptoms and, crucially, still ‘accept’ the patient.


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Econometric analysis of where spending should be focused

Another approach to determining the value of investment in the early years is based on econometrics. The mainproponent of this approach is the Nobel Laureate Professor James Heckman. Essentially, his analysis states that structures (including knowledge and skills) are based on foundations and the stronger the foundations the moresolid the structure.

In financial terms, he argues that investment early in getting the foundations of knowledge and social skills right in a young child creates compound benefits. A child who is confident, emotionally stable and interested inlearning learns (much) faster and more effectively than a child who is fearful or depressed, or who cannot controlhis emotions. It follows that when you spend money on children in later interventions (and Heckman says wemust) then the rate of return on such later interventions is much higher for those children on whom you first spent early (but much lower from those you allowed to slip through that part of the net). He produces tables, figures andcalculations which show how this would work, and validates this with evidence showing much higher returns for early years’ than for later intervention programmes.

In ‘The Case for Investing in Disadvantaged Young Children’ (Heckman 2008) he states his argument in 15points:

1. Many major economic and social problems such as crime, teenage pregnancy, dropping out of highschool and adverse health conditions are linked to low levels of skill and ability in society.

2. In analyzing policies that foster skills and abilities, society should recognize the multiplicity of humanabilities.

3. Currently, public policy in the U.S. and many other countries focuses on promoting and measuringcognitive ability through IQ and achievement tests. A focus on achievement test scores ignoresimportant non-cognitive factors that promote success in school and life.

4. Cognitive abilities are important determinants of socioeconomic success. 5. So are socio-emotional skills, physical and mental health, perseverance, attention, motivation, and self-

confidence. They contribute to performance in society at large and even help determine scores on thevery tests that are commonly used to measure cognitive achievement.

6. Ability gaps between the advantaged and disadvantaged open up early in the lives of children. 7. Family environments of young children are major predictors of cognitive and socio-emotional abilities, as

well as a variety of outcomes, such as crime and health. 8. Family environments in the U.S. and many other countries around the world have deteriorated over the

past 40 years. A greater proportion of children is being born into disadvantaged families includingminorities and immigrant groups. Disadvantage should be measured by the quality of parenting and not necessarily by the resources available to families.

9. Experimental evidence on the positive effects of early interventions on children in disadvantagedfamilies is consistent with a large body of non-experimental evidence showing that the absence of supportive family environments harms child outcomes.

10. If society intervenes early enough, it can improve cognitive and socio-emotional abilities and the healthof disadvantaged children.

11. Early interventions promote schooling, reduce crime, foster workforce productivity and reduce teenagepregnancy.

12. These interventions are estimated to have high benefit-cost ratios and rates of return. 13. As programs are currently configured, interventions early in the life cycle of disadvantaged children have

much higher economic returns than such later interventions as reduced pupil-teacher ratios, public jobtraining, convict rehabilitation programs, adult literacy programs, tuition subsidies, or expenditure onpolice. The returns are much higher than those found in most active labour market programs in Europe(See Heckman, LaLonde and Smith, 1999; and Martin and Grubb, 2001).

14. Life cycle skill formation is dynamic in nature. Skill begets skill; motivation begets motivation. Motivationcross-fosters skill and skill cross-fosters motivation. If a child is not motivated to learn and engage earlyon in life, it is more likely that in adulthood, he or she will fail in social and economic life. The longer society waits to intervene in the life cycle of a disadvantaged child, the more costly disadvantage is toremediate.

15. A major refocus of policy is required to capitalize on knowledge about the importance of the early yearsin creating [or reducing] inequality and in producing skills for the workforce.

Heckman points to the evidence that enriching the early environments of children in low income familiesproduces significant financial returns, citing in particular the Perry Preschool and Abecedarian Programs becausethey use random assignment designs and collect long-term follow up data. Their findings are confirmed by data


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from the Nurse Family Partnership (Karoly et al, 1998; Olds, 2002) and the Chicago Child-Parent Center’sprogrammes (see above).

Commenting on the high reported rates of returns of Perry and other early years’ programmes Heckmanobserves that these rates of return are likely to be understated because they ignore the economic returns fromsuch investments in improving health and mental health. As mentioned earlier, this omission is a recurring sourceof underestimate of benefits in evaluations of early years’ programmes, yet the ACE Studies referred to above(e.g. Felitti and Anda, 2010) show the very significant impact of early adverse experiences on a range of healthoutcomes including heart, liver and lung disease, diabetes, obesity, alcoholism, drug abuse, depression andattempted suicide, most of which are not included in the calculations of benefits referred to above.

Heckman contrasts the 14% return of the Perry Program with the (then) standard 7.2% stock market equityreturn. He also compares it favourably with published evaluations of the returns from public job trainingprogrammes, adult literacy services, prisoner rehabilitation programmes and education programmes for disadvantaged adults. Heckman is famous for his graph of estimated returns from investment in children at different ages.

Heckman’s conclusion, like that of Rolnick and Grunewald, is that from a purely financial perspective, society isunder-investing in early years.

Heckman also points out a particular characteristic of early years’ investment, not found with investments in later years. It is very common in public investments to find a trade-off between equity (giving benefit to those whoneed it most) and efficiency (creating benefit where returns are highest). Heckman argues (Cunha and Heckman, 2007b; Heckman and Masterov, 2007) that because early years’ interventions both promote economic efficiencyand reduce lifetime inequality, they provide policy makers with a rare ability to spend money in a way whichdelivers both social and economic benefits at the same time.

Approach to early years’ investment based on neurobiology

Drawing on the full breadth of intellectual resources available across Harvard University’s graduate schools andaffiliated hospitals, the Harvard Center on the Developing Child generates, translates, and applies, knowledge inthe service of improving life outcomes for children in the United States and throughout the world.


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The Center’s goal is to promote healthy child development, economic prosperity, strong communities, and a just society, and their mission is to advance that vision by the use of science to inform policy making.

The Science of Early Childhood Development is one of a series of reviews by the Center. Focusing on thechallenge of ‘Closing the Gap Between What We Know and What We Do’, this report states as one of its major conclusions that creating the right conditions for early childhood development is likely to be more effective andless costly than addressing problems at a later age.

The report explains that as the maturing brain becomes more specialised to assume more complex functions, it isless capable of reorganising and adapting to new or unexpected challenges. Once a circuit is ‘wired’, it stabiliseswith age, making it increasingly difficult to alter.

Plasticity is maximal in early childhood and decreases with age. Although ‘windows of opportunity’ for skilldevelopment and behavioural adaptation remain open for many years, trying to change behaviour or build newskills on a foundation of brain circuits that were not wired properly when they were first formed requires morework and is more ‘expensive’. For the brain, this means that greater amounts of physiological energy are neededto compensate for circuits that do not perform in an expected fashion. For society, this means that remedialeducation, clinical treatment, and other professional interventions are more costly than the provision of nurturing, protective relationships and appropriate learning experiences earlier in life. Stated simply, the report says gettingthings right first time is more efficient and ultimately more effective than trying to fix them later.

The report draws the following conclusions from the study of the science:

Implications for Policy and Practiceo These findings direct our attention to the importance of informal family support and formal preventive

services (when needed) for vulnerable children before they exhibit significant problems in behaviour or development. When policy makers ensure that all young children who are at high risk for poor outcomesare enrolled in high quality programs whose effectiveness has been documented, the returns are far greater than those achieved when only a subgroup of eligible children are served.

o The basic principles of neuroscience and the process of human skill formation indicate that earlyintervention for the most vulnerable children will generate the greatest payback. Although the largenumber of children and families who could benefit from additional assistance will require significantincreases in funding, extensive research indicates that investment in high quality interventions willgenerate substantial future returns through increased taxes paid by more productive adults andsignificant reductions in public expenditures for special education, welfare assistance, and incarceration.

o Research indicates that policy makers can achieve greater return on investments in early childhoodeducation for children from families with low incomes and limited parent education than from remedialprograms for adults with limited workforce skills. In fact, long-term studies show that model programs for three- and four-year-olds living in poverty can produce benefit-cost ratios as high as 17:1 andannualised internal rates of return of 18% over 35 years, with most of the benefits from theseinvestments accruing to the general public. While it is not realistic to assume that all scaled-up earlychildhood programs will provide such handsome returns, it is likely that benefit-cost ratios still will beconsiderably greater than 1:1.

o The essence of quality in early childhood services is embodied in the expertise, skills, and relationship-building capacities of their staff. The striking imbalance between the supply and demand for well-trainedpersonnel in the field today indicates that substantial investments in training, recruiting, compensating, and retaining a high quality workforce must be a top priority for society. Responsible investments inservices for young children and their families focus on benefits relative to cost. Inexpensive services that do not meet quality standards are a waste of money. Stated simply, sound policies seek maximum valuerather than minimal cost.

Whole country approach to early years’ prevention

Sweden

In UNICEF’s 2007 Report Card 7: An overview of child well-being in rich countries, (UNICEF 2007), averagingrankings on 6 measures of child well-being shows the two countries leading the international league table of childwell-being are the Netherlands and Sweden. Both countries have made a commitment to a preventive approachto child welfare.


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The countries of Scandinavia have consistently led international comparisons in terms of welfare (Wilkinson andPickett 2009). Recognising the value of prevention and early intervention programmes, in the last 20-30 yearsthese countries have increased this type of investment (Killén 2000; Socialstyrelsen 1997).

A 2008 study by Heiervang, Goodman et al, investigating children’s externalising and internalising problems inboth Norway and Britain, discovered that Norwegian children scored lower on all problem scales (emotional, behavioural, hyperactive and peer relationship) on the Strengths and Difficulties Questionnaire, according toparents as well as teachers. The prevalence of externalising disorders (behavioural and hyperactivity) in Norwaywas about half that observed in Britain.

A comparison of societal child welfare between the UK and Scandinavia shows marked differences in a range of factors. Maternity healthcare services in Sweden are accessed by the vast majority of pregnant women (99 per cent), who typically have 11 individual contacts, mostly with midwives. Ninety-eight per cent of all maternityhealthcare clinics offer parenting education in groups to first-time parents, with 60 per cent allowing repeatparents to participate. Additional support in the form of specialised groups is provided to those mothers withparticular needs, for example young mothers, single mothers and those expecting twins.

Ninety-nine per cent of all families make use of the child healthcare services in Sweden. They have an averageof 20 individual contacts, primarily with nurses. Parents are invited to join parent groups when the child hasreached the age of one to two months. In Stockholm County for example, 61 per cent of all first-time parentsparticipated in at least five sessions in 2002 (Bremberg 2006). Parent education accounts for around 8-10 per cent of midwives working time; 65 per cent of midwives received regular professional training on the subject, and72 per cent were instructed by a psychologist (Socialstyrelsen 1997).

At 2.5 per cent, the infant mortality rate in Sweden was the lowest in the EU in 2005 and half that in the UK.Sweden also performs well on a number of health indicators from later life; the country has the third lowest mortality rate in the EU from cancer and circulatory diseases, amongst the lowest rates for deaths due to chronicliver disease and smoking related causes, and has the highest life expectancy in the EU for men (and the thirdhighest for women). In addition Sweden has the third-lowest rate of teenage pregnancies in the European Unionat 1.6 per cent, compared to 7.1 per cent in the UK (only several Eastern European countries have a greater number than Britain). Given the poor relative life prospects for children of teenage mothers, this also contributesto better long-term outcomes in Sweden.

SWEDEN(2005)

UK(2005)

% Of Live Births To Mothers Under 20 Yrs 1.6 7.1Infant Mortality

te per 1,000 live births2.5 5.1

Smoking dail smokers a ed 15 and ove

15.9 25.0

Alcoholnnual pure alcohol litres per person

6.9 11.4

Adult Obesity of population

10.7 23.0

Smoking Related Deathse standardised per 100,000 pop’

195.5 244.9

Chronic Liver Disease Deaths, Under 65 Yrs (per 100,000 pop’n) 4.0 9.5Cancer Deaths, Under 65 Yrs

e standardised per 100,000 pop’n56.0 67.5

Circulatory Disease Deaths, Under 65(age standardised per 100,000 pop’n)

31.9 43.3

These figures strongly imply a well-resourced and professional healthcare service in Sweden, with a strong focuson prevention, and starting at the very beginning of life with emphasis on breast-feeding (55-60% of Swedishmothers are exclusively breastfeeding at 4 months, 7% in the UK). In addition long periods of maternity andparental leave support attention to the needs of the child in its earlier months. 100% of hospitals have BFHI (baby-friendly) status (less than 10% in the UK) and early parent training is provided for a high proportion of thepopulation. From that strong beginning it is able to improve its user’s quality of life through helping them to avoidmany preventable illnesses, and enabling the country to save money on both the healthcare and non-healthcarecosts of those illnesses.

The difference between the UK and Sweden is hard to explain by reference to different levels of spending onhealth. The countries spend almost identical proportions of their GDP on health, and while Sweden’s GDP ishigher the slightly greater spend per head of population is far short of that needed to produce such differences in


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health outcomes. Sweden also spends much less on health, both as a percentage of GDP and per head than theUnited States, but with much better health outcomes, infant mortality and life expectancy. We suggest Sweden’ssuccess reflects how it spends its health money rather than how much it spends.

The approach of an American public policy advisory group

Washington State Institute for Public Policy (WSIPP)

The Washington State Institute for Public Policy (WSIPP) was created by the 1983 Washington Legislature tocarry out non-partisan research assignments. The 2009 Legislature directed the Institute to ‘calculate the returnon investment to taxpayers from evidence-based prevention and intervention programs and policies.’ TheLegislature instructed the Institute to produce ‘a comprehensive list of programs and policies that improveoutcomes for children and adults in Washington and result in more cost-efficient use of public resources.’

For nearly 30 years WSIPP has been evaluating the payoffs from specific programmes and identifying thosewhich produce the highest return. WSIPP uses a four step research approach:

1. Systematically assess evidence on ‘what works’ (and what does not) to improve outcomes.

2. Calculate costs and benefits for Washington State and produce a Consumer Reports-likeranking of public policy options.

3. Measure the riskiness of their conclusions by testing how bottom lines vary when estimatesand assumptions change.

4. Where feasible, provide a ‘portfolio’ analysis of how a combination of policy options could affect

state-wide outcomes of interest.

Their analyses produce two key bottom-line statistics: an expected value of overall benefits minus costs, and anestimate of the risk that a given strategy could produce negative net benefits. Since WSIPP was first set up theyhave conducted thousands of evaluations and identified many hundreds of programmes which produce positiveoutcomes. Their work has been extremely influential in driving Washington State towards a more evidence-basedand rational set of investments, particularly for youth programmes, which has been their main area of focus.

In their evaluations of Child Welfare programmes WSIPP estimates the following returns (WSIPP, July 2011):

Topic Area/ProgramMonetaryBenefits Cost

Benefit to Cost ratio

Return on Investment

Nurse Family Partnership for Low-IncomeFamilies 30,325 9,421 3.23 7%Incredible Years: Parent Training and ChildTraining 15,571 2,085 7.5 12%Other Home Visiting Programs for At riskFamilies 14,896 5,453 2.73 5%

Healthy Families America 13,790 4,508 3.07 7%Parent-Child Interaction Therapy: DisruptiveBehavior 9,584 1,302 7.37 31%

Parent-Child Interaction Therapy: Child Welfare 9,498 1,516 6.27 15%

Intensive Family Preservation (Homebuilders®) 10,995 3,224 3.41 4%

Incredible Years: Parent Training 8,488 2,022 4.2 12%

Triple P5: Level 4 7,237 1,790 4.06 19%

Triple P: Level 4 3,740 365 10.32 n/e

Parents as Teachers 7,236 4,138 1.75 5%

Triple P: (Universal) 1,277 139 9.22 8%

They estimate, on average, that 30% of benefits go to the taxpayer and 70% to the family.

The WSIPP evaluation approach is conservative, and likely to under-estimate the benefits of many early years’programmes. In setting up a rigorous evaluation system there is always a tension between a system whichcreates false negatives and one which creates false positives. The WSIPP system is strongly designed to avoidfalse positives. They do not include some significant areas of benefit in their calculations, and arguably under-


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value others. Their policy of significantly reducing the reported benefits of many of the studies they utilise isprudent (avoiding potential optimistic bias due to studies carried out by the programme developer, or due to aweak evaluation design, for example). However they have no mechanism to increase reported benefits when astudy evaluation omits known benefits. They are aware of the under-evaluation of economic benefits due toexcluding ACE-type health savings, or ignoring the monetary value of breaking cycles of family violence or druguse, but prefer an approach with minimal risk of recommending a programme which might fail to deliver theprojected benefits.

This rigorously ‘safe’ approach allows WSIPP to make recommendations with a high degree of confidence. Theirtop eight juvenile justice programmes, for example, have an average probability of delivering positive economicbenefits of over 90%. Similarly, in adult criminal justice, they have identified 10 programmes with 100%probability of delivering economic benefits, and a further three with a 99% probability. The lack of risk in theirpolicy recommendations makes them very popular with state legislators, and their many crime-focused effortshave paid off. Relative to national rates, juvenile crime has dropped in Washington State, adult criminalrecidivism has declined, total crime is down, and taxpayer criminal justice costs are lower than alternativestrategies would have required (Aos et al, 2011).

An inevitable feature of the ultra-safe WSIPP approach is that their age focus leans heavily towards later years, when the gap between intervention and financial benefit is shortest. A 2011 analysis of the age spread of a rangeof evaluations carried out by WSIPP between 1990 and 2011 found a ratio of more than 30 to 1 in number of evaluations of programmes related to school children or youths, compared with those related to infancy. Thispresumably reflects the focus of their political commissioners on the age groups which cause them most problems.

The innate caution in the WSIPP assumptions can be seen from the following (provisional) comparison of thebenefits of preventing a case of child abuse, using three sources: WSIPP, Cohen, Piquero and Jennings; and anAustralian estimate conducted at Monash University in Melbourne by Taylor, Moore et al (2008).

Lifetime costs of abuse (i.e. value of preventing one case of abuse) in US $

Cost category WSIPP Cohen et al Taylor, Moore et alChild Health treatment 1,901 21,622 3,468Additional educational assistance Not included Not included 3,397Productivity losses of survivors 4,887** Not included 1,690Productivity losses due to premature death Not included Not included 905Crime 169** 70,000 4,381Government expenditure on care andprotection

5,719 Not included 23,809

Costs of alcohol and drug abuse 13** Not included Not includedtransaction costs of other costs Not included Not included 9,706Sub-total: Costs to society exc. Illness 12,689** Not included 47,355Depression, anxiety, suicide Not included Not included 60,767Other long-term health costs Not included Not included Not includedSub-total: Costs to society 12,689** 91,622 108,123

Cost in terms of suffering of victim 22,948 178,378 Not included

Total Costs 35,637** 260,000 108,123

This table is highly provisional, as communication with the authors will be required to bring the cost estimates to aconsistent basis. We could not find data for the items marked ** in the WSIPP column, but have estimated thesefrom a WSIPP evaluation of the benefits of the Nurse Family Partnership. The figures may be overstated. Noneof the three approaches includes the long-term health costs for liver, lung, heart disease etc due to ACEs such aschild abuse.

Karoly (2010), in a report calling for more standardised approaches to cost-benefit analyses, identifies thefollowing benefits found by WSIPP in studies of Nurse Family Partnership (NFP) and Infant Health andDevelopment Program (IHDP), but not valued by them:

NFP: Emergency room use; Earnings (and taxes); Welfare use (mother); Total births & birth-spacing (mother); Substance abuse (mother).

IHDP: Achievement tests, IQ scores, Mother-child interactions, Home environment.


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ConclusionAs stated in the opening of this report, there is a great deal of massively compelling evidence in favour of thecost-effectiveness of primary preventive intervention at the earliest possible time in the life cycle. Whether programmes address maternal nutrition during pregnancy, promoting breastfeeding, understanding the cues of tiny babies or ensuring pre-schoolers develop social and emotional competence as well as the basic cognitiveskills needed to learn, the strong message is that young life rewards early support. Such support must often bedelivered via the prime caregiver(s) – typically the mother. If we want an affordable society that works well, weneed to invest in the best possible, evidence-based early years’ programmes to address this issue.

Table S.1Early Childhood Intervention Programs Included in Karoly, Kilburn and Cannon (2005) Study

Home Visiting or Parent Education

Nurse-Family Partnership (NFP)Developmentally Supportive Care: Newborn Individualized Developmental Care and Assessment Program(DSC/NIDCAP)*Parents as Teachers*Project CARE (Carolina Approach to Responsive Education)—no early childhood educationHIPPY (Home Instruction Program for Preschool Youngsters) USAReach Out and Read*DARE to be YouIncredible Years

Home Visiting or Parent Education Combined with Early Childhood EducationEarly Head Start*Syracuse Family Development Research Program (FDRP)Comprehensive Child Development Program (CCDP)Infant Health and Development Program (IHDP)Project CARE (Carolina Approach to Responsive Education)—with early childhood educationCarolina Abecedarian ProjectHouston Parent-Child Development Center (PCDC)Early Training Project (ETP)High/Scope Perry Preschool ProjectChicago Child-Parent Centers (CPC)Head Start

Early Childhood Education OnlyOklahoma Pre-K

NOTES: Programs marked with an asterisk are designated as having a promising evidence base because asubstantial number of children were as young as age 2 or 3 at the time of the last follow-up. All other programs are designated as having a strong evidence base.


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SECTION 2 – UK studies

The economics of UK-based early years’ interventions

Having reviewed the international evidence-base for the economics of early years’ intervention, this section isdevoted specifically to UK-based evaluations. We examine these across a range of assessments:

While there is a significant amount of American research evidence for the cost-effectiveness of well-designedearly years’ interventions, there is much less data from the UK, where there has been a historical reluctance tofund early years’ research because of its assumed long-term nature. This is one factor making such research(and especially Randomised Control Trials) relatively more expensive than studies for older age groups. As aresult, few evaluations have been carried out in relation to UK-based early years’ prevention and interventionprogrammes. Those which have been conducted have often been on low budgets and with a limited scope. Oftensuch evaluations have been methodologically flawed.

Within these limitations there have been varied approaches to evaluating early years’ interventions, includingcost-benefit analyses (with or without randomised control trials), case studies and social return on investment studies. There have also been predictive studies, at both macro and micro level, which have compared the costsof comprehensive systems of intervention with projected savings from avoidance of the costs of dysfunction. Qualitative, quantitative and mixed method research studies all have useful information and insights about thesuccess (and comparative value) of interventions during the early years.

The ‘cost of inaction’ approach

There have been UK-focused analyses that point to the very high costs of dysfunction (in individual/social terms) and the very low cost, by contrast, of interventions to prevent those high costs. These studies appeal to thecommon sense and judgement that early years’ investment makes good sense in both economic and humanterms. This ‘ounce of prevention is better than a pound of cure’ approach has been adopted by such countries asSweden and the Netherlands, which top the UNICEF child wellbeing tables.

In the UK, such organisations as Action for Children, C4EO, the Centre for Social Justice and WAVE Trust, andsuch Government-commissioned reports as the Allen and Field Reviews, have produced persuasive analyses forthe case that early years’ investment makes good sense and would save substantial sums of public money.

Scotland: Christie Commission and the Scottish Parliament FinanceCommitteeIn Scotland, the Christie Commission (Christie, 2011) has estimated that 40% of public spending is created bythe failure to intervene early enough to prevent dysfunction.

The Scottish Parliament asked its Finance Committee to conduct a study of the merits of preventive spending,with a particular focus on the early years. After nine months of taking evidence, the Committee’s work wassummarised by former Health and Finance Minister Tom McCabe, who said:

‘I will not spend time on the statistics that we heard about during the inquiry, because there are enoughexperts and committed individuals in the chamber who already know the basis of the evidence. Theyknow that there is empirical evidence stacked from the floor to the sky that backs up our taking adifferent approach to preventative spending and investment in the early years.’

The Scottish Government, with cross-party support from the Scottish Parliament, has pressed ahead with anagenda to promote early years’ preventive spending. In support of this it has declared that there has been a‘decisive shift’ to preventive spending and ‘a step change in the way in which we fund and deliver public services. To support this approach the Scottish Government introduced a new Early Years and Early Intervention ChangeFund and, in partnership with Local Government, the NHS, the Police and the Third Sector, set up an Early YearsTaskforce (and, most recently, the nationwide Early Years Collaborative) to ‘take forward a significant changeprogramme to help deliver the joint commitment to prioritising the early years of children’s lives and to earlyintervention’ (Scottish Government, 2012). Its objectives include to:

o Put Scotland squarely on course to shifting the balance of public services towards early intervention andprevention by 2016.

o Sustain this change to 2018 and beyond.

Study by GLA Economics for the Greater London Authority This study provided evidence for, and analysis of, the case for investment in early years’ interventions to addresshealth costs and inequalities in London. The study highlighted the high costs (£13,000-£65,000 annually perchild) of mental illness, emotional and behavioural disturbances, or antisocial behaviour, and cited the joint


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LSE/Institute of Psychiatry study which estimated £70,000 per head direct costs to the public of children withsevere conduct disorders versus £600 per child cost for parent training programmes. The report concludes:

‘The evidence shows that well designed and implemented early years programmes can have significant benefits in terms of life-long health, educational attainment, social, emotional and economic wellbeingand reduced involvement in crime that far outweigh their costs… Programmes implemented in thecritical pre-natal, post-natal and pre-school periods can have very high returns.’

The GLA Economics report recommends a series of pre-natal, post-natal and pre-school programmes from conception through to age 5, noting that the earliest years of a child’s life provide the opportunity for the greatest benefits, with cumulative effects throughout the child’s life. (Greater London Economics, 2011)

Evaluation of the Parenting Early Intervention ProgrammeBehaviour problems during early and middle childhood are associated with antisocial behaviour duringadolescence and increased risk of negative outcomes in adulthood. The consequences of these can be veryexpensive for society and, on the assumption that successful parenting is a key element in preventing childrendeveloping behavioural difficulties, the Parenting Early Intervention Programme (PEIP, 2008-11) was set up toprovide government funding to all 150 local authorities in England to deliver selected parenting programmes withproven efficacy in improving parent outcomes and associated reductions in children’s behavioural difficulties. (Lindsay et al, 2011)

An evaluation report examined the effectiveness in everyday use in community settings across England of fiveparenting programmes initially selected by the government for use in the PEIP: Families and Schools Together (FAST); Positive Parenting Program (Triple P); Strengthening Families Programme 10-14 (SFP 10-14); Strengthening Families, Strengthening Communities (SFSC); and The Incredible Years.

All five programmes had an evidence base for improving parent and child outcomes when tested in small scale, controlled trials. The evaluation examined whether these outcomes could be maintained and replicated when theprogrammes were rolled out nationally and implemented in all local authorities in England.

The evaluation found that: Triple P, Incredible Years, SPF 10-14 and SFSC were effective in improving outcomesfor parents and children; these outcomes were maintained one year on from the end of the programme; and thebeneficial effects on parents’ mental well-being and style of parenting, as well as children’s behaviour, are all keyprotective factors for achieving positive long-term child outcomes.

Crucially, PEIP achieved comparable improvements in child behaviour (as reported by parents) to those achievedin the previous small scale studies. Costs were not large. For instance, reducing conduct problems and the totallevel of 'difficulties' measured using the Strengths and Difficulties Questionnaire required an average cost between £3,300 and £4,300. Parental gains were even more economical. For each measurable unit of improvedparental mental well-being, reduced parenting laxness, and reduced parenting over-reactivity, the cost wasbetween £2,000 and £2,600.

Over the PEIP as a whole, the cost of a parent training intervention, including infrastructure, was £1,658 per parent, with one local authority sustaining a three-year average cost of only £534.

Thames Valley PartnershipThames Valley Partnership carried out an evaluation (Ball, 2001) of eight early intervention programmes targetedat children in areas of multiple disadvantage and high levels of crime. Some of the programmes worked with pre-school children and families, some with children in the first years at primary school. The researchers found all theprogrammes, at low cost, had some beneficial effect on children, their parents and their schools, or on all threetogether. The younger the child, the more pronounced the effects on behaviour. While the study did not include aformal cost-benefit analysis, the authors stated:

‘These interventions have had an effect on parenting and the behaviour of the children involved, andthey are not expensive.’

Case study approach

Both North-East London Foundation Trust (NELFT) and the University of Salford have carried out case studyanalyses of early years’ interventions in practice.

NELFTIn the NELFT cases, the main costs were for the time of a Consultant Perinatal Psychotherapist.


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In their Case 1, a suicidally depressed 17-year-old mother was living in an environment of domestic violence witha 6-week-old baby who was becoming hypervigilant, depressed, thwarted and dissociated. The treatment cost £8,208.

Following perinatal mental health intervention, the child is now 8 years old and thriving; the mother is with a newand stable partner, has had 3 more baby boys and experienced no difficulties with them. There is no domesticabuse. The intergenerational transmission of trauma has been broken. The estimated costs to health and socialservices alone, if treatment had not taken place, would have far exceeded the cost of the intervention, without even taking account of predictable extra expenditures on the children’s schooling, criminal justice and physicalhealth costs in the long term, or inter-generational effects.

NELFT Case 2 was of a 23-year-old mother, referred when 6 months pregnant suffering from escalatingaggression and anti-social tendencies with a diagnosis of Borderline Personality Disorder. She had lost custodyof two previous children. Treatment cost £5,265.

In Case 2, the baby is now securely attached to both mother and father and the mother is now studying 3 ‘A’levels with a plan to seek employment.

In both examples the absence of intervention was reliably projected to have resulted in highly expensiveconsequences in terms of the costs of lasting damage to parent and child and the costs to health services of dealing with these.

University of SalfordThe University of Salford (UoS) carried out two case study analyses (Livesley et al, 2008) of an intervention toprovide a budget-holding leading practitioner to families with very young children or babies. The project promotedmore effective early intervention through earlier identification of, and response to, unmet needs.

In UoS Case 1 there were children aged 6 years, 5 years, 2 years and 6 months. Previous family history hadincluded sexual abuse of two of the girls by the mother’s previous partner. Neither mother nor current partner wasworking, and they were in debt. The property was sparsely furnished, uncarpeted and partially fire-damaged. Concerns were raised by the family health visitor about the home environment and the social and emotionaldevelopment of the children. Intervention in this case cost £6,768.

In UoS Case 2 there were 4 children aged 4 and 3 years and twins of 18 months. The mother was pregnant. Their house was cramped, in poor condition, unsafe and too small. The father was unemployed and could bevolatile following the effects of a traumatic motoring accident. The children and the mother were all showing signsof stress and the twins and 3-year-old were displaying developmental delay and behaviour problems. Interventionin this case cost £16,868.

In the UoS Cases, costs were a mixture of (mainly) providing professional support through midwives, healthvisitors, lead practitioners and others, and (at a lower level) such practical help as provision of beds and carpets,or payment for Montessori sessions for some of the children.

Professionals engaged with the families projected the likely cost consequences if the support had not beenprovided. The benefits (i.e. future costs avoided) exceed the intervention costs in Case 1 if there is a 9% or higher probability of realising the professionals’ projections; in Case 2 benefits exceed the costs if there is a 16%or higher probability of realising the projections. The judgement of the practitioners is that the costs avoidedsignificantly exceed the costs of the interventions.

Social return on investment (SROI) approach

SROI is a form of adjusted cost-benefit analysis that puts a value on some less tangible outcomes, such asimproved family relationships. It considers the benefits that accrue from services to a range of stakeholders, children, families and communities.

C4EO analyses of Social Return On Investment (SROI)

Early years’ intervention to increase breastfeeding

Blackpool Children and Young People’s Department developed Children’s Centres that welcomed breastfeeding, ensured staff directed queries about breastfeeding to both professional and voluntary sources, and set upsupport groups. The Primary Care Trust (PCT) provided training to staff and the Children’s Centres promoted the‘Be a Star’ campaign aimed at increasing the perceived value of breastfeeding to young women. The PCT andChildren’s Centres worked in partnership to reach out to mothers in disadvantaged areas who were predictablyless likely to breastfeed.


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Breastfeeding support groups were developed, breastfeeding training was made available to frontline staff andthe first satellite breast milk bank centre in the UK was set up, as was a signposting service to breastfeedingmothers and their partners.

Breastfeeding initiation rates rose from 42% to 56% over a 2-year period, an increase sustained over thefollowing two years. 903 vulnerable young mothers received targeted support at a cost of £29,811, or £33 per mother. The SROI reported by C4EO was £1.56 for every £1 invested, and the estimated savings to local healthservices were £57,500, e.g. from reduced GP and A&E visits, over a two-year period (C4EO, 2010).

I CAN Early Talk, KentConcern about the number of children with severe speech, language and communication needs requiring aspecialist unit place in a primary school led to a joint partnership agreement with I CAN to develop Kent’s first specialist Early Talk centre. The aim was to offer a targeted, multi-agency approach to supporting young childrenwith severe speech, language and communication needs, so that they could participate in everyday activities andattend their local primary school – empowering parents as co-educators in a programme that could be deliveredin a nursery, children’s centre or home.

The Ashford Better Communicators Service established a virtual team including a Speech and LanguageTherapist (SLT), a Learning Support Assistant, a children’s centre teacher, an Early Years Special EducationalNeeds Coordinator and staff from a nursery based in a children’s centre. A referral pathway was established andtargets set in partnership with the parents. Parents received regular support from both the virtual team and adedicated parents’ support group.

Four years after the programme was designed 92% of the children supported attended their local primary schooland made good progress, rather than requiring specialist language provision; 70-80% had increased their understanding and use of language to an extent greater than was predicted without this intervention. Thesuccess of the programme led to its roll-out to other areas of Kent.

The programme was delivered to 37 children at a project cost of £46,300, with an SROI of £1.37 for every £1 invested. This translates into estimated savings of £17,131 over the anticipated extra costs for these children inthe absence of this intervention.

New Economics Foundation (nef) / Action for Children

As part of the Backing the Future study for Action for Children, the New Economics Foundation (nef) conductedSocial Return on Investment (SROI) analyses on three Action for Children projects (Nef, 2009). Two of theseinterventions, one in Doncaster and one in East Dunbartonshire, impacted the early years:

Wheatley Children’s Centre, DoncasterWheatley Children’s Centre (WCC) in Doncaster has aims geared towards achieving the goals of ‘Every ChildMatters’ by promoting the following outcomes:

1. Be healthy2. Stay safe3. Enjoy and achieve 4. Make a positive contribution5. Achieve economic well-being

WCC has developed theories of change for all their activities to explain how their children’s activities achieve theabove outcomes, and the Centre provides a mixture of universal and targeted services to children aged 0-5.

Nef calculated an SROI ratio for WCC of 4.6:1, i.e. an estimated £4.60 worth of social value was generated for every £1 spent on the programme. Nef carried out a number of sensitivity analyses on the results. Thesesuggested the conclusions were robust; for example, for the most significant outcomes (by value) of education,mental health and family relationships, a halving of the unit proxy values resulted in a reduction in the SROI to nolower than 3.7.

The Doncaster analysis provides interesting data for those reflecting on the relative merits of universal servicesvs. those targeted at high-need children alone. High Need children at WCC represented only 8% of the number of children being supported and gained 27% of the benefit from the service while 73% of the financial benefit camefrom the 92% of children categorised as Low Need. Despite the projected benefits lasting for a shorter period oftime for the latter group, the group size (over 800) offset the shorter benefits period.


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East Dunbartonshire Children’s CentreThis service provided short-term, focused and flexible support for children, young people and families in crisis. Itsgoals were to reduce the number of children being looked after and accommodated; assess more accuratelychildren’s needs; support parents better to meet their children’s needs; and help children and young peopleaddress issues that may be affecting their lives and well-being.

Project staff worked intensively with families for a period of 8 to 12 weeks. Referrals were made by social workerswith the permission of families.

The SROI calculated by nef was £9.20 return for every £1 invested. The most significant value (34%) wasobtained by the state, which recouped its investment by the end of one year. This was primarily through thereduction in need for foster care and its associated costs. Children and families also derived significant benefits. Parents benefited from the changes in behaviour and social skills of their children, and from their ownimprovements in confidence, self-esteem and anger management, as well as broader parenting skills andknowledge. Children benefited from the improved parenting skills of their parents, and better behaviour of their siblings. Most of the value was delivered within the first three years, but there is significant value to both childrenand the state in the longer term.

Barnardo’s – 4 early years’ services

A set of SROI evaluations on early years’ services provided by Barnardo’s was carried out by the internationalconsultancy firm, ICF GHK (Mason et al, 2012).

Stay and Play, BournemouthStay and Play groups are delivered weekly, for families with children under the age of 2, with weekend groups ona bimonthly basis and some groups targeted at families with such particular needs as English as an AdditionalLanguage. Stay and Play sessions offer parents opportunities to: build networks of support with their peers; receive parenting and childcare advice and guidance; and receive signposting to other services.

Benefits identified included improved confidence of parents; improved knowledge of parenting strategies; improved English language skills for children with English as an Additional Language; improved diet; increasedaccess to physical activities; parents’ promoting children’s play and learning; improved progress in children’slearning and development; reduced social isolation; reduced obesity; and improved parenting. ICF GHK calculated an SROI of £2 for every £1 invested.

Family Support Workers, WarwickshireFamily Support Workers (FSWs) at Evergreen Children’s Centre in Warwickshire provide families with childrenunder 5 who have additional needs with intensive one-to-one support.

Referrals to the service are made by health, education, voluntary and community sector organisations, andstatutory services. Following referral an initial assessment takes place to assess the specific needs of families. These families are then matched with an FSW. FSWs discuss and agree a package of tailored support responding to the families’ needs, taking account of the families’ views. Support is discussed with families on anon-going basis and closed with their agreement.

Benefits identified included improved parenting skills; improved confidence of parents; reductions in the level of risk / harm to children; safer home environments; improved access to information on housing, health, benefits, rights or support needs; reduced numbers of families accessing high level services; reduced social isolation of families; improved family relationships; and carers promoting children’s play and learning. The consultancy firmcalculated an SROI of £4.50 for every £1 invested.

Tiny Toes: Hazlemere and Loudwater Children’s CentresThe Tiny Toes service supports expectant teenage and young mothers and their babies. It brings motherstogether in a safe, fun and educational environment, allowing Tiny Toes to address a range of complex issuesexperienced by mothers.

The service is intensive; Tiny Toes staff make it as easy as possible for the expectant mothers to attend. Thisincludes providing very strong encouragement and even picking mothers up and taking them to appointments. A wide range of support includes cooking and preparing food; supported play; training towards accreditedqualifications; trips to events and attractions; and specific issues delivered by expert professionals.

Benefits identified included improved parenting skills; improved parental confidence; reduced social isolation; improved family health; reduced levels of risk / harm to children; improved resource management by parents; andparents’ accessing employment, education and /or training. Tiny Toes was judged to deliver an SROI of £3.50 for every £1 invested.


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Triple P: Brock House, SomersetAt Brock House Children’s Centre in Somerset, parents attending the Triple P parenting programme are in needof additional support to manage their child’s behaviour but are not amongst those at risk of having their childrentaken into care. Families are referred to the service by a range of agencies and a crèche is provided to support attendance.

Four weekly group sessions are delivered by a Project Worker and a Parenting and Family Support Advisor(PFSA), plus two further weeks of telephone support. If additional support is required, home visits are provided. On completion of the programme, parents are encouraged to build relationships with their peers and continue toaccess such universal services as Stay and Play.

Benefits identified included improvements in parental confidence; social networks; knowledge of parenting; familyrelationships; and child behaviour. Triple P was estimated to deliver an SROI of £2.50 for every £1 invested

In commenting on their methodology, ICF GHK state that in valuing outcomes they have taken a conservativeapproach, and where they have been unable to establish a plausible financial valuation for specific benefits havesaid so and excluded them from the final ratio. They conclude: ‘This means that the results presented are, if anything, an underestimation.’ Sensitivity analyses suggested the results were stable when key variables weremodified.

Cost-benefit analyses

Commissioners frequently need to make difficult choices between alternative investments. In making suchchoices it is valuable to know not only which spending decisions deliver the desired results, such as improvedmental health or improved parenting, but also what (if any) economic benefits flow from different decisions. Cost-benefit analysis compares these factors for specific programmes or policies and adds to the information availableto commissioners.

NICE (The National Institute for Health and Clinical Excellence) and other organisations use a standard andinternationally recognised method to compare clinical effectiveness: the quality-adjusted life years measurement (the ‘QALY'). Although one intervention might help someone live longer, it might also have serious side effects. Another treatment might not help someone to live as long, but it may improve their quality of life while they arealive (for example, by reducing pain or disability). The QALY method gives an idea of how many extra months or years of life of a reasonable quality a person might gain as a result of treatment.

NICE Assessment Group evaluation of parent-training/education programmes

A NICE Assessment Group evaluation of Parent-training/education programmes in the management of childrenwith conduct disorders (NICE 2009) concluded there was evidence of effectiveness for such programmes. Thecosts of conduct disorder were found to be high: £63,000 higher per child than for those with no problems, and£24,324 per child higher than for children with the less serious diagnosis of conduct problems.

The Assessment Group concludes that, for children with conduct disorders, these programmes are cost-saving, with the majority of the savings accruing to education and health services. The Assessment also noted possibleadditional savings, beyond those in their evaluation, from youth justice, adult healthcare and social services. Thereport states:

‘The Committee was persuaded therefore that a wide variety of public services stood to benefit from theappropriate implementation of parent-training/education programmes.’

Morrell et al (post natal depression)

Morrell et al (Morrell et al, 2009) carried out a randomised cluster trial to estimate any differences in outcomes for women with post-natal depression, (and their families and infants) who received two different forms of psychologically informed treatment in intervention groups (IGs), delivered at GP practice (cluster) level, compared with the health visitors’ usual care as the control group (CG). The secondary aim was to establish therelative cost-effectiveness of the intervention from an NHS perspective.

While there were weaknesses in the study (e.g. missing data) the authors concluded:

‘The results show a consistent pattern of psychological approaches being cost-effective at fundinglevels used by NICE. This was achieved by lower mean costs and higher mean QALYs [QualityAdjusted Life Years] gained in the Intervention Group. Although these aggregate differences are not statistically significant in isolation, in combination they produce a high probability of the interventionbeing good value for money.’


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London School of Economics study for the Department of Health

Mental health promotion, prevention and early intervention

This study was set up to identify and analyse the costs and economic pay-offs of a range of interventions inmental health promotion, prevention and early intervention. The approach and assumptions were conservative –i.e. designed to under-state rather than over-state benefits - across all areas investigated. (Knapp et al, 2011) Weinclude here two interventions, one addressing post-natal depression in the first year; the other addressingparenting programmes for conduct disorder when children were aged 5. Although this is outside the 0-2 agerange which is the focus of our report, it does give an indication of the economics of a parenting intervention atage 5, and NICE itself recommends addressing conduct disorder at as early an age as possible, stating:

‘Prognosis is particularly poor in early-onset conduct disorders, reinforcing the importance of earlyeffective treatment. More than 60% of 3-year-olds with conduct disorders still exhibit problems at theage of 8 years if left untreated, and many problems will persist into adolescence and adulthood. Approximately half of children diagnosed with conduct disorders receive a diagnosis of antisocialpersonality disorders as adults, with others being diagnosed with psychiatric disturbances includingsubstance misuse, mania, schizophrenia, obsessive-compulsive disorder, major depressive disorder and panic disorder’.

http://www.nice.org.uk/nicemedia/pdf/TA102guidance.pdf

1. Post-natal depressionAn evaluation of a health visiting intervention to reduce post-natal depression was compared with routine careafter childbirth. The authors found that, over a one-year time horizon, and excluding benefits to fathers or infants, there were no cost savings, because lower treatment costs and reduced workplace productivity loss wereoutweighed by increased training and higher staff costs. Over the longer term, however, the model predicted cost savings from reduced treatment costs and productivity losses (where depression persists) together with savingsin costs of negative behavioural, emotional and cognitive consequences for the children of mothers who sufferedfrom post-natal depression. The authors comment that their methodology is likely to produce conservativeestimates of benefits, both because of conservative assumptions and because no monetary value was put on thehealth and quality of life gains for the beneficiaries, i.e. the children of these mothers.

2. Parenting programmes for conduct disordersAn evaluation of parenting programmes targeted at parents of 5-year-old children with, or at risk of, conduct disorders found parent training to have positive effects on children’s behaviour, and that the benefits persist. Thestudy’s economic model calculated total gross savings over 25 years of £9,288 per child, exceeding the cost ofthe intervention by a factor of 8 to 1. No benefits were assumed from such wider impacts as improvedemployment prospects, reduced adult mental health issues and improved outcomes for the child’s family andpeers, which the authors suggest are likely to be substantial. If accurate, then this would make the intervention aneven better investment than reported. As noted above, the earlier in the child’s life such parenting programmesfor conduct disorder are delivered, the earlier their benefits will begin to accrue.

Randomised control trials (RCTs)

While there are numerous RCTs of early years’ interventions showing good evidence for economic value fromother countries, few RCTs assessing economic benefit have been conducted in the UK. We found two: the SocialSupport and Family Health Study; and the Oxfordshire Home Visiting Study. Findings were very mixed; this is notsurprising in view of the particular intervention designs chosen. Despite the caveats, both offer valuable learning.

Social Support and Family Health StudyThe Social Support and Family Health (SSFH) study began 14 years ago and ran for 3 years. It was delivered towomen in deprived districts of Camden and Islington.

Two initiatives were assessed: home-based listening support by health visitors, and the services of communitysupport organisations. Both were compared with routine services. The primary outcomes of interest were childinjury, maternal smoking and maternal psychological well-being; with secondary interest in health, health serviceuse and changes in household resources.

In essence, the home visiting arm tested the value of providing non-intrusive listening support of about 7.5 hoursin total length, over a 12-month period, for new mothers. Although the service was primarily a listening one, health visitors did provide advice if asked. The service was very popular with most mothers, especially becauseof its focus on what the mother wanted to talk about, with a minority of mothers finding the visits to be pointless.

Fewer than 20% of mothers allocated to community support groups used the services. Home visitingorganisations had a higher uptake than those requiring the mother to drop in.

http://www.nice.org.uk/nicemedia/pdf/TA102guidance.pdf


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At 12 months post-randomisation the study found slightly lower levels of depression, child injuries and maternalsmoking in the intervention groups, and higher levels of reported good health for children. However, none of these results were at a sufficient level to eliminate chance as an explanation. Both intervention groups reportedbetter health than control group women. Overall, 18% of women in the health visitor group and 19% of community group women said they had poor health, compared with 26% of control group women.

The study found no evidence that the interventions produced economic benefits; on the other hand they cost nomore than routine services, small savings matching their low costs.

The modest results of the experiment were not a surprise to the service providers. The researchers stated in their summing up:

‘The apparent inability of either intervention significantly to improve major health outcomes is consonant with the views stated in the process evaluation by the providers of both interventions. The view wasexpressed that social support alone, whether given by health visitors or by community services, isunlikely to be able to counteract the health-damaging effects of social and material disadvantage,including the stresses and difficulties that are a normal part of many mothers’ lives in countries such asthe UK today.’ (Wiggins et al, 2004)

Given that approximately 40 minutes per month of extra ‘listening’ took place, it is difficult to imagine the benefitsoriginally anticipated accruing from such a modest intervention.

Oxfordshire Home Visiting to reduce child abuseThe Oxfordshire Home Visiting Study evaluated the effectiveness of a professionally delivered, intensive home visiting programme beginning during the antenatal period and continuing for one year after birth. It thus lastedapproximately 18 months, compared with 30 months for the Family Nurse Partnership programme (Barlow et al, 2008).

It was designed to improve parenting and child outcomes, including the prevention of abuse and neglect. Itsrecipients were 131 high risk women, with children who were not necessarily the first for those parents – again acontrast with Family Nurse Partnership, which focuses on first-time mothers (as they tend to be more malleable intheir parenting behaviours).

This is a complex study to interpret. Some of the benefits it delivered – greater maternal sensitivity and greater infant cooperativeness in the first 12 months – were not repeated at 3-year follow-up. However there is researchevidence that it is sensitivity in the first 12 months of life that is most crucial to child outcomes (Martin, 1981, Shaw and Winslow, 1997)

In addition, children in the intervention group who suffered maltreatment were more likely to be detected, andmore likely to suffer maltreatment for shorter periods of time. These findings were not at a level of statisticalsignificance, due largely to the small numbers involved. The authors comment that the findings may be clinicallysignificant, in particular because of the benefits of identifying abuse at as early an age as possible, and mighthave reached statistical significance in a larger trial. These findings could be of very significant economic value.

On some subsidiary measures, the control group performed better than the experimental group. It is perhaps worth looking at the findings on detection of abuse in detail, as these bear heavily on the economicevaluation:

Intervention Group Control GroupNumber of Participants 66 60Children re whom concern registered by healthor social services professionals

19 (28.8%) 13 (21.7%)

Physical abuse concern 1 ( 1.5%) 1 ( 1.7%)Neglect concern 11 (16.7%) 8 (13.3%)Emotional abuse concern 7 (10.6%) 4 ( 6.7%)

There was marginally more concern and proactive engagement in the intervention group, while child deaths werehigher in the control group.

Intervention Group Control GroupNumber on Child Protection Register 6 4Children removed from home long-term 6 4Children who died 0 2


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One child removed long-term from home, in the control group, had had their name placed on the Child ProtectionRegister twice in the preceding years, and was finally removed from home due to neglect at age 4.

Of the two children who died, the coroner recorded an open verdict on one with child protection concerns; in theother case, a paediatrician involved had a high level of concern about non-accidental bruises on the child, but thechild died before a child protection investigation could take place.

Economic evaluationIn the three-year follow-up report, Barlow et al state that the results suggest that intensive home visiting improvedmaternal sensitivity at 12 months and better enabled health visitors to identify infants in need of further protectionat an incremental cost of £3,985 per woman over 36 months, and conclude:

‘The extent to which these potential benefits are worth the costs, however, is a matter of judgment.’

The following remarks address that judgement – tentatively, because the numbers in the study are too small toexclude the possibility of the results merely reflecting chance.

Cohen, Piquero and Jennings (Cohen et al, 2010) have identified the present value lifetime cost of child abuseand neglect in the United States as being US $250,000-285,000. This equates at a November 2012 exchangerate to £166,864 in UK money. A UK professor with experience in this field suggested that UK costs of abuse andneglect are unlikely to vary much from those in the US, with some components being higher and some lower. Thus the detection of even one additional case of abuse or neglect would provide an economic payback on thecost of detection indicated in the Oxfordshire study provided that only one additional child was saved from harmfor every 41.9 mothers (i.e. £166,894 divided by £3,985) receiving the intensive health visiting service.

The tables above show two fewer child deaths in a cohort of 66 mothers receiving the home visiting intervention, and six more children (7%) about whom concern has been registered. While the numbers involved are too smallto eliminate chance as an explanation of these figures, at face value the intervention is protecting children at significantly above the level needed to break-even and deliver a financial benefit. Again, at pure face value, assuming just two were saved from abuse or neglect by the intervention (not implausible given four more childrenwere placed on the risk register or removed from home, two fewer died, and many others received more sensitiveparenting), the cost would have been:

66 x £3,985 = £263,010

And the saving would have been

2 x £166,984 = £333,788

This represents a 27% return on investment – in line with the assertions of both Professor James Heckman and the Federal Reserve Bank of Minnesota that early years’ investments far exceed stock market returns. Further,this apparent pay-off does not factor in any benefit from improved maternal sensitivity (i.e. it ignores the benefitsto all other children from improved quality of parenting, or of the value of the health benefits of reducing ACEs inthe children’s lives). Given that a single form of abuse (e.g. neglect or emotional abuse) has been shown by

Felitti and Anda (2009) to result in between a 30% and 70% higher rate of heart disease in the victims, andCohen at al (2010) have estimated that a single case of heart disease costs about $150,000 (£93,750), the 27%ROI calculation could be quite conservative. However, to repeat, these are very tentative conclusions given thesmall numbers involved.

Subsidiary measuresOn a number of subsidiary measures the outcomes for the control group were better than those for theintervention group (12 vs 18). This study was of a very high risk sample of mothers – the average number of riskfactors (such as mental health problems, domestic violence, drug and alcohol abuse) in the intervention groupwas 5.4 for each mother (4.8 in the control group). The designer of the intervention, Professor Hilton Davis,believes that to be truly effective with families suffering such severe and multi-faceted problems would involve:

a support team of experts to provide the health visitors with easy access for relevant referral (e.g. tohousing and/or psychiatric support), andmore extensive training in the ‘partnership’, rather than the ‘expert’, model of interaction between

parents and health professionals.

Given the conditions, the cut-off point of the support might have been too early, but might be effective with lesscomplex families, or where there was a circle of expert support available for referral, or both.


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Predictive studies

Finally we look at three predictive studies, two at a macro and one at a micro level, each of which compared thecosts of systems of prevention or early years’ intervention with projected savings from avoiding the costs of dysfunction in the lives of children.

At a macro level, two UK charities, Action for Children and WAVE Trust, have recommended a conscious switchof policy in the UK from remedial interventions after harm has occurred to investment in preventing harm fromhappening in the first place. Using quite different costing methodologies, both of these third sector organisationshave projected major benefits to society – including financial ones – from such a preventive strategy.

Both studies assumed a national commitment to transformational change in levels of disadvantage and adverseoutcomes for society. At a micro level, Croydon NHS Trust and Croydon’s local authority conducted a joint study,

the Croydon Total Place report, with the more modest aim of simply improving the outcomes of the most disadvantaged children and families in their borough. The following table summarises the costs and benefitspredicted by the three studies, with the Croydon figures uplifted (pro rata to population) to national (UK) scale for comparison:

£ billion

Predicted Costs Predicted Benefits Return per £ investedAction for Children £619.7 £1,499.9 £ 2.42WAVE Trust £ 97.0 £ 686.1 £ 7.07Croydon NHS & LA upliftedto national scale

£ 12.7 £ 144.8 £11.44

On a Net Present Value basis, the Croydon returns fall to £9.82 per £ invested. On the basis of thesecomparisons, the Action for Children predictions look quite conservative, which they claim to be.

The Action for Children model assumes the need for much higher universal costs than the WAVE Trust model,while the Croydon Total Place approach includes neither the costs of targeted interventions, as recommended byboth WAVE and Action for Children, nor the comprehensive investment in improved universal services proposedby the latter.

Macro Studies

Action for Children / New Economics Foundation

In Backing the Future: why investing in children is good for us all (Action for Children and New EconomicsFoundation, 2009), a joint report by Action for Children and the New Economics Foundation, the authors cite theextensive evidence of the harmful effects that social problems such as drug use, crime, inequality, familybreakdown, and poor mental health can have on children’s well-being and their future life chances, and observethat these negative outcomes are being transmitted from generation to generation, perpetuating and deepeningcycles of inequality and disadvantage. They then calculate the costs of doing nothing to improve social problemsin the UK over the next 20 years and project these to be almost £4 trillion.

The authors then propose a twin-track approach to minimise this cost, and its associated waste of human capitaland quality of life. First, to break the vicious cycle of inter-generational disadvantage, they propose a series of targeted interventions for the most ‘at risk’ children, young people and families. Second, to make these

improvements permanent and to consolidate deeper structural change, they propose a set of universalinterventions, the phasing in of a more holistic approach to children’s services along the lines of the most

successful European countries, with access to universal high-quality childcare and properly funded parentalleave, coupled with proven support services and delivery models.

The study uses data from the Washington State Institute for Public Policy both to cost the targeted programmes, and to estimate their effectiveness in reducing negative outcomes such as drug abuse, crime, teenage births andmental illness. Effectiveness was assumed to be half that found by evaluations, to avoid over-claiming. Inestimating the effectiveness of the projected increase in preventative universal services, the authors identified thetop performing countries in terms of child well-being and social outcomes and assumed a switch to social policies


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that appear to produce better outcomes in these countries, such as high-quality universal child care, well-fundedparental leave and attention to improving the quality of early interactions between children and their parents. These were costed assuming both the need for fixed costs such as building facilities and training staff, and therunning costs of delivering the improved services. Returns from investment in universal services were assumedin two forms: reduced spending on existing measures such as cash transfers to reduce child poverty (whichinternational comparison suggests are less effective than improved universal services), and savings fromimproved positive outcomes after children reach 10 years of age. The assumption is that without significant investment in universal services, the improvements in outcomes from the targeted interventions will not besustained.

It should be noted that while the increased investments in universal services proposed are essentially early yearsand prevention focussed, the targeted interventions include several which are not early years.

This very detailed and carefully reasoned approach produces forecasts of total new spending of £620 billion(£428.3 universal and £191.4 targeted), and savings of £1.5 trillion (£1,039.84 billion from universal and £460.7billion from targeted). The calculations of benefits produce predicted returns on investment of £2.43 per £1invested for improved universal services, £2.41 per £1 invested for targeted services (the similarity of thesefigures being coincidental), and £2.42 per £1 invested overall.

WAVE Trust

Operating with a much smaller budget for evaluation, the approach of WAVE Trust produced similar conclusions. In this case an Excel-based computer model was set up to predict changes in levels of child maltreatment(physical abuse and neglect) as part of WAVE’s campaign to reduce child maltreatment by 70% in the UK by

2030 – i.e. its 70/30 strategy. While the economic evaluation is much less sophisticated than the nef/Action forChildren approach, the model’s operational assumptions led to it being described by the Centre for Social Justice

as the leading-edge computer model of its kind when created in 2010, and it was used by the Cabinet Office, alsoin 2010, as input to its studies.

The computer model explores one possible way (not necessarily the recommended way) in which the challengeof reducing child maltreatment by 70% by 2030 might be approached. The model, designed by Brojo Pillai, takesthis shape:

1. It begins with the cohort of children born in the first year of this comprehensive intervention andassumes a certain proportion of families are vulnerable - i.e. their children are at risk of beingmaltreated.

2. It uses validated screening instruments to identify families at different levels of vulnerability (Level 1 = noconcern, Level 4 = grave concern).

3. Families identified to be vulnerable (Levels 2, 3 and 4) are encouraged to participate in a set of evidence-based interventions. Some families may require a strong incentive to participate in theinterventions; for some, who are severely maltreating their children, participation may be mandatory.

4. The interventions proposed were selected as part of an international review of best practice. They haveproven to be effective in preventing child maltreatment, or addressing its consequences.

5. Over the course of the year, these vulnerable families are exposed to a number of interventions. Eachintervention has a certain effectiveness in terms of its likelihood to have a particular positive impact on afamily's vulnerability. Effectiveness is measured by a set of values that are representative of both theintervention and the level of vulnerability of the family.

6. At the end of each intervention, a certain number of families would have become less vulnerable tomaltreatment. Some families will move from the highest level of vulnerability (Level 4) to a lower level(Level 3). Some may even move out of the radius of vulnerability (to Level 1).

7. The goal is to move at least 70% of families who would otherwise be within the radius of vulnerability(Levels 4, 3 or 2) outside of that radius (to Level 1).

8. At the end of the first year, and a set of interventions later, a number of families would have made that move to Level 1.


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9. At the start of the second year, the whole cohort is screened again, using a screening instrument appropriate to that age group (the one-year-olds). Once again, families at different levels of vulnerabilityare identified (Level 1 to Level 4). The number of families at Level 1 would be higher this time, becauseof the previous year's interventions.

10. Families who are still at Levels 2, 3 and 4 are offered another set of interventions, appropriate for thisage group (one-year-olds). Again, these interventions were carefully selected as part of an internationalreview of best practice.

11. This process of screening and offering interventions to the families who need them, continues until thechild turns age 16. A number of universal interventions are also included, and these are offered tochildren and families at all Levels (1, 2, 3 and 4).

12. Interventions assumed include First Steps in Parenting, Front Pack Baby Carriers, Video InteractiveGuidance, Family Nurse Partnership, Circle of Security, Triple P, Incredible Years, Mellow Parenting, Roots of Empathy, the Dorset Healthy Alliance and a domestic violence reduction programme.

13. Unit costs for each intervention were calculated, typically through discussion with the interventioncreators, such as Dr David Olds for Nurse Family Partnership. Costs of running these interventions at the scale required were calculated at each stage.

14. As the first cohort moves into the second year of the 16-year schedule, a new cohort is born, and theymove through the first year of the 16-year schedule. In the third year there is a new cohort movingthrough the first year of the schedule, another cohort moving through the second year, and a cohort moving through the third year of the schedule. This process continues until, 16 years later, there are 16cohorts simultaneously experiencing the programme. An estimate of the cost of doing this, and the likelyresult of doing this, was then calculated. The model followed a narrative laid out in the Excel worksheet.

15. To summarise its results, the model suggests we can reduce the risk of child maltreatment in the UK by84% within 16 years, at a total cost of £97 billion. Further, we can reduce the risk of maltreatment for asingle birth cohort by 79% over the next 4 years, at a cost of £5.1 billion. The computer model wasdriven by a number of assumptions, and was designed to allow users to see, instantly, the impact of changing any or all of these assumptions.

16. The author comments that the possible cost of £97 billion over 16 years may, at first glance, seem high, or unaffordable. However, against this may be set the costs being incurred as a result of adverse earlychildhood experiences. These were estimated more conservatively than in the nef/Action for Childrenmodel, at £429 million. The author concludes that if just 10% of these costs can be avoided as a result of the interventions, it would repay the investment seven times over. Moreover the £97 billion is mainly aone-off cost over a 16-20 year period, whereas the benefits would flow for a much longer time scale(Pillai, 2010).

Micro Study

Croydon local authority and Primary Care Trust, after an exhaustive study through the Treasury-initiated TotalPlace analysis of all money spent in their area, concluded (NHS Croydon and Croydon Council, 2010) that theintroduction of an early years’ preventive strategy with a particular focus on preparation for parenthood, beginning

with maternity services, would lead to a return on investment of more than £10 per £1 invested.

The Croydon approach planned to focus service redesign on 4 wards in the borough, approximately 15% of theoverall population, identified on the basis of high levels of need and poor outcomes. An improved early years’

infrastructure and a limited set of universal propositions were to be implemented borough-wide.

A key assumption arising from the Croydon study was that it was possible to make very substantial savings over time. The report stated:

‘We believe it is possible to achieve radical efficiency: innovations which both release significant cost

savings as well as improvements in outcomes. At the same time as increasing the volume andeffectiveness of prevention and early intervention work, we have calculated the savings that we willmake over time: short term savings in specific service areas and medium term savings particularly inreducing our spending on cost of failure – services dealing with poor outcomes in older children and


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young people. In both cases these cut across service providers, with a focus particularly on NHS Croydon and Croydon Council.

In keeping with HM Treasury finance, we have applied discounted rate over time (Net Present Value) toour figures. We anticipate savings on an NPV basis of over £8.4m during the spending period 11/12 -13/14, £25m by the end of the next spending period (ending 16/17) and more than £63m by the time our current 4 year olds turn 18 in 23/24. These calculations are net of up-front investment costs as well asnew revenue costs, and are based only on implementing our main propositions in 4 of our wards: wetherefore believe our estimations are conservative.’

The report goes on to forecast savings outside the borough, and to recommend investment in early years’

prevention approaches across public bodies more widely:

‘It is clear that we will also deliver substantial long term savings to the public purse, as we reduce the

number of young people who end up in the justice system and in prison, and increase the number of children who grow up to be economically active, net contributors to society, capable of parentingeffectively themselves. We have not sought to estimate these long term savings at this stage, but theyare likely to be very significant, and accrue to public bodies beyond the boundaries of Croydon. A systems thinking approach would suggest a strong case for these services to invest in early years’

intervention as part of their own preventative agendas.’

Croydon Total Place echoes the financial findings of Action for Children, RAND and Reynolds, and supports therecommendations of the Federal Bank of Minnesota, Heckman and the Harvard Center on the Developing Child(see international economics section), that investment in early years’ prevention is worthwhile, and far exceedsthe returns of stock market investments, but from a uniquely English and local-based perspective.


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References

Appendix 4(1) - International Section

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(2007).The Science of Early Childhood Development: Closing the Gap Between What WeKnow and What We Do. National Scientific Council on the Developing Child. Harvard University, USA.Center for the Developing Child. (2010). In Brief: Early Childhood Program Effectiveness, Harvard University, USA.Cohen, M.A. (1998). The monetary value of saving a high-risk youth. Journal of Quantitative Criminology. 14, 5–33.Cohen, M.A. Piquero, A.R. Jennings, W.G. (2010). Estimating the Costs of Bad Outcomes for At Risk Youth and the Benefits ofEarly Childhood Interventions to Reduce Them. Criminal Justice Policy Review, 21(4), 391-434.Cohen, M.A. Piquero, A.R. (2009). New evidence on the monetary value of saving a high-risk youth. Journal of QuantitativeCriminology. 25(1), 25–49.Cunha, F. Heckman, J.J. (2007). The technology of skill formation. American Economic Review, 97(2), 31–47.Currie, J. Hyson, R. (1999). Is the Impact of Shocks Cushioned by Socioeconomic Status? The Case of Low Birth Weight.American Economic Review, 89(2), 245–50DCSF. (2009). Referrals, assessment and children and young people who are the subject of a child protection plan, England -Year ending 31 March 2009. Available: http://www.education.gov.uk/rsgateway/DB/SFR/s000873/sfr22-2009t1t13.xls. Lastaccessed 22nd Jan 2013. See Tables 4A, 4C, 5B in Excel tables.Department for Children, Schools and Families. (2009). Referrals, Assessments and Children and Young People who are theSubject of a Child Protection Plan, EnglandFelitti, V.J Anda, R.F. (2009). The Relationship of Adverse Childhood Experiences to Adult Medical Disease, PsychiatricDisorders, and Sexual Behavior: Implications for Healthcare. In Lanius, R. Vermetten, E. (Eds) The Hidden Epidemic: TheImpact of Early Life Trauma on Health and Disease, Cambridge University Press, UK.Felitti, V. Anda, R. (2010). The Relationship of Adverse Childhood Experiences to Adult Health, Wellbeing, Social Function andHealth Care. In Lanius, R. Vermetten, E. Pain, C. (Eds) The Effects of Early Life Trauma on Health and Disease: The HiddenEpidemic, Cambridge University Press, Cambridge Chapter 8.Heckman, J.J. (2008). Schools, Skills and Synapses. Economic Inquiry, 46(3), 289-324.Heckman, J.J. Masterov, D. (2005). Skill Policies for Scotland. In Coyle, D. Alexander, W. Aschroft, B. (Eds) New Wealth forOld Nations : Scotland's Economic Prospects, Princeton University Press, Princeton, NJ, 119-65.Heiervang, E. Goodman, A. Goodman, R. (2008). The Nordic advantage in child mental health: separating health differencesfrom reporting style in a cross-cultural comparison of psychopathology. Journal of Child Psychology and Psychiatry, 49(6), 678-685.House of Commons Committee of Public Accounts. (2010). Tackling problem drug use. Thirtieth Report of Session 2009-10. Parliament Publications, London.Karoly, L.A. Kilburn, M. R. Cannon, J.S. (2005). Early Childhood Interventions: Proven Results, Future Promise. Prepared forThe PNC Financial Services Group, Inc.Karoly, L.A. Kilburn, M.R. Cannon, J.S. (2005). Early Childhood Interventions Proven Results, Future Promise. Santa Monica,CA: RAND Corporation.Karoly, L.A. Greenwood, P.W. Everingham, S.S. Hoube, J.M. Kilburn, R.C. Rydell, P. Sanders, M. Chiesa, J. (1998) Investingin Our Children: What We Know and Don't Know About the Costs and Benefits of Early Childhood Interventions, RAND, SantaMonica, California.Killén, K. (2000). Barndommen varer i generasjoner (Childhood lasts for generations). Oslo, Kommuneforlaget, Sweden.Lewit, E. M. Baker, L. S. Corman, H. Shiono, P. H. (1995). The direct cost of low birth weight. Future Child, 5(1), 35-56.Olds, D.L. (2002). Prenatal and Infancy Home Visiting by Nurses: From Randomized Trials to Community Replication.Prevention Science, 3(3), 153-172.Reynolds, A.J. Temple, J.A. White, B.A.B. Ou, S-H. Robertson, D.L. (2011). Age 26 Cost–Benefit Analysis of the Child-ParentCenter Early Education Program, Child Development, 82(1), 379–404.Reynolds, A.J. Temple, J.A. (2008). Cost-Effective Early Childhood Development Programs from Preschool to Third Grade.Annual Review of Clinical Psychology, 4,109–39.Rolnick, A. Grunewald, R. . (2003). Early Childhood Development: Economic Development with a High Public Return. Available: http://datacenter.spps.org/uploads/ABC-Part2.pdf. Last accessed 21st Jan 2013.Scottish Government (2012). Children's Social Work Statistics Scotland, No.1: 2012 Edition. http://www.scotland.gov.uk/Publications/2012/02/7586/11Socialstyrelsen. (1997). Stöd i föräldraskapet (Support in Parenting). Socialdepartementet (Dept. for Social Welfare, HMGovernment). SOU 1997:161. Sweden.Taylor, P. Moore, P. Pezzullo, L. Tucci, J. Goddard, C. De Bortoli, L. (2008). The Cost of Child Abuse in Australia, AustralianChildhood Foundation and Child Abuse Prevention Research, Australia: Melbourne.Tickle, L. (2010). Is early intervention under threat from spending cuts? Guardian: NovemberUNICEF. (2007). Child poverty in perspective: An overview of child well-being in rich countries. Available: http://www.unicef-irc.org/publications/pdf/rc7_eng.pdf.Welsh Government (2012). CARE0024: Number of children and young persons on the Child Protection register at 31 March byage at 31 March. Knowledge and Analytical Services, Welsh Government, Cardiff. Available athttps://statswales.wales.gov.uk/Catalogue/Health-and-Social-Care/Social-Services/Childrens-Services/Service-Provision/ChildrenOnChildProtectionRegister-by-LocalAuthority-CategoryOfAbuse-AgeGroup


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Wilkinson, R. Pickett, K. (2009). The Spirit Level: Why More Equal Societies Almost Always Do Better. Allen Lane, UK.

Appendix 4(2) - UK Section

Action for Children. New Economics Foundation. (2009). Backing the Future: why investing in children is good for us all. NewEconomics Foundation, London.Ball, M. (2001). Early Years’ Intervention Projects - A Report on the Evaluation Study. Thames Valley Partnership and CrimeConcern, Aylesbury.Barlow, J. Davis, H. McIntosh, E. Kirkpatrick, S. Peters, R. Jarrett, P. Stewart-Brown, S. (2008). The Oxfordshire Home VisitingStudy: 3 Year Follow-up. University of Warwick, Warwick.C4EO. (2010). Grasping the nettle: early intervention for children, families and communities. London.Christie, C. (2011). Commission on the Future Delivery of Public Services. Scottish Government, Edinburgh.Cohen, M.A. Piquero, A.R. Jennings, W.G. (2010). Estimating the Costs of Bad Outcomes for At-Risk Youth and the Benefits ofEarly Childhood Interventions to Reduce Them. Criminal Justice Policy Review, 21(4), 391-434.Davis, H. Day, C. (2010). Working in Partnership with Parents. 2nd Edition. Pearson, London.Greater London Economics. (2011). Early years interventions to address health inequalities in London – the economic case.Greater London Authority, London.Knapp, M. McDaid, D. Parsonage, M. (2011). Mental health promotion and mental illness prevention: The economic case. Department of Health, London. Lindsay, G., Strand, S., Cullen, M.A., Cullen, S.M., Band, S., Davis, H., Conlon, G., Barlow, J., Evans, R. (2011). ParentingEarly Intervention Programme Evaluation. Research Report DFE-RR121(a). London: Department for Education.Livesley, J. Long, T. Murphy, M. Fallon, D. Ravey, M. (2008). Evaluation of the Blackpool Budget-Holding Leading PractitionerProject. University of Salford, Salford. Martin, J. (1981). A longitudinal study of the consequences of early mother-infantinteraction: a microanalytic approach. Monographs of the Society for Research in Child Development. 46(3).Mason, P. Salisbury, D. Mathers, I. (2012). The Value of Early Intervention: findings from Social Return on Investment researchwith Barnardo’s children’s centres. ICF GHK, Birmingham.Morrell, C.J. Warner, R. Slade, P. Dixon, S. Walters, S. Paley, G. Brugha, T. (2009). Psychological interventions for postnatal depression: cluster randomised trial and economic evaluation. The PoNDER trial. Health Technology Assess,13(30).New Economics Foundation. (2009). Backing the Future: SROI report The economic and social return of Action for Children’sWheatley Children’s Centre, Doncaster. London.NHS Croydon and Croydon Council. (2010). Child: Family: Place: Radical efficiency to improve outcomes for young children.Croydon Council, Croydon.NICE. (2006). Assessment Group evaluation of parent-training/education programmes in the management of children withconduct disorders, London.Pillai, B. (2010). How could we reduce child maltreatment in the UK by 70%, and at what cost? WAVE Trust, London. Scottish Government. Scottish Spending Review 2011 and Draft Budget 2012-13. September 2011.Available:http://www.scotland.gov.uk/Resource/Doc/358356/0121130.pdf.Scottish Government. (2012) The Early Years Taskforce: Shared Vision and Priorities. Available at http://www.scotland.gov.uk/Resource/0038/00389841.doc.Shaw, D.S. Winslow, E.B. (1997). Precursors and correlates of antisocial behaviour from infancy to preschool. In Stoff, D.M.Breiling, J. Maser, J.D. (Eds.) Handbook of Antisocial Behaviour. Wiley, New York.Wiggins, M. Oakley, A. Roberts, I. Turner, H. Rajan, L. Austerberry, H. Mujica, R. Mugford, M. (2004). The Social Support andFamily Health Study: a randomised controlled trial and economic evaluation of two alternative forms of postnatal support formothers living in disadvantaged inner-city areas. Health Technol Assess, 8(32), iii, ix-x, 1-120.


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APPENDIX 5

Systems

Background

It was proposed that the s stems sub- roup provide an anal sis of the chan in local delive context and identiopportunities to improve support and outcomes for vulnerable 0-2s and their families (including antenatally). To achievethis goal, the group focused on addressing the following exam question:

In a world of increased localism – what are the levers and incentives to turn the rhetoric of early interventioninto evidence-based support on the ground for vulnerable families with babies?

The roup prepared an outline of the ke s stems and levers of influence in the context of local workin arran ementscurrentl for the 0-2 a enda. These would be the s stems and levers for ke SIG messa es and findin s to becommunicated to and throu h.

Key conclusions

These are laid out in tabular form in the following pages.


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Levers Action

Localstructures andprocesses

Creation of Joint Health & Well Being Boards

Use of Joint StrategicNeeds Assessments(JSNAs) to inform localcommissioning

Community budgets

Formation of clinicalcommissioning groups(CCGs)

Provide clear information about the importance of pregnancy to age 2 instatutory guidance and other non-statutory communications for ‘shadow’and emerging Health & Wellbeing Boards.

Provide clear information about the importance of measures aroundpregnancy-2s and their parents in statutory guidance and other materialsabout JSNAs. Support LAs to find and collect the relevant data (e.g.through improving data collection, information sharing etc.). Recruit aDPH champion to explain how to incorporate 0-2s into the JSNA.

Encourage a community budget approach as an aspiration for thepregnancy-2 stage using learning from Total Place sites. Use economicexamples where possible.

Link with commissioning champions (where in post in LAs) and find achampion GP to take early action to make sure 0-2s and preventive workare made a priority in the minds of the CCGs.

Frameworks Public health outcomesframework

Healthy Child Programme(HCP)

New Health Visitor (HV) Offer

Core Purpose of Children's Centres

Pregnancy, Birth andBeyond – new frameworkfor antenatal education

NICE guidance e.g. onantenatal and postnatalmental health

Early Years FoundationStage

Influence the inclusion of indicators in the Children and Young People’spublic health outcomes strategy and framework around earlier outcomes/risk factors in conception and infancy and maternal mentalhealth. Ensure the 2/2.5 placeholder indicator takes into account infant mental health/social and emotional development and knowledge about neuroscience developments. Use of evidenced based tools such asASQ-SE in reviews of children at age 2/2.5.

Use all opportunities to help DH refresh HCP to build on the frameworkand integrate new models and practice that have a good evidence base. For example, HCP could include more on assessment of attachment andspecialist pathways, parental and infant mental health, drug and alcohol, domestic abuse, relationships and links to pregnancy, birth and beyond.

Use HV training programme to enhance the curriculum for all HVs, ensuring they receive high quality modules in attachment theory, parent-infant interaction, child development, video interaction guidance.

Link with relevant DfE team to ensure revisions to Sure Start Children’sCentres statutory guidance includes clear evidence on parental riskfactors (to support local decisions about targeting) and guidance about effective information sharing.

Government to develop a strategy to ensure that antenatal educationusing this framework is available for all new parents. Disseminatethrough links to NCT and build links to NHS operating framework.

Refresh framework and/or provide resources and showcase effectivemodels and incentives to encourage and enable local services tocommission effective support in all areas.

Feedback the 0-2 findings about supportive family environments and theimportance of attachment and attunement to the relevant DfE policyteam as part of any further revision/maintenance work to the Early YearsFoundation Stage.


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Data/measures Children's Services DataProfile (Being developedby Association of Directors of Children’sServices) ADCS andothers to enablebenchmarking to improveLA performance)

Improve measures of out-comes/risk factors in 0-2s

Public Health Indicators(included in the outcomesframework)

Clarify the best links to ADCS and Children Improvement Board (CIB) toensure the profile contains plenty of data for conception-2, including therisk factors for neglect and abuse. Research what the priorities for CIB will be for 2012/13.

Explore how to further improve recording and reporting of infants' socialand emotional development and attachment, and of parental risk factorsin parents (and parents-to-be).

Ensure proposed indicators capture the impact of early parenting andinfant mental health (see box 1 above).

Workforce Measures to improveearly years’ workforce -including new early yearsteaching centres andtraining in integratedcentre leadership

Nutbrown review of earlychildhood workforce.

Ensure a focus on attachment and infant mental health, not just earlylearning. Link to National college/Teaching Agency and the NPQICLwork.

Explain the concept of workforce emotional intelligence. Include astrong focus on identification of early attachments and interventions tosupport secure attachment in any response to the Nutbrown review.

Investment policy priorityand funding

Making Early Interventiona Priority

Look for opportunities to influence emerging policy about the importanceof pregnancy-2 and infant mental health as part of the Early Interventionagenda (e.g. links to Frank Field work, BIG Lottery – A better start).Feed into revised 'working together' document and EYFS consultation.

Inspection Ensure Ofsted and CQC are assessing howchildren's care and healthsettings are working toimprove safety andwellbeing duringconception-2.

Ensure Ofsted and CQC are assessing how children's care and healthsettings are working to improve safety and wellbeing during conception-2.